A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.

Electrical cord on floor over walkway.

Uses a cane to ambulate.

Unsecured throw rugs over tile floor in kitchen.

Macular degeneration.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
An electrical cord on the floor over a walkway can pose a tripping hazard, increasing the risk of falls. It’s important to keep walkways clear of any obstacles to prevent falls.
Choice B rationale
Using a cane to ambulate does not necessarily increase the risk of falls. In fact, canes are often used to improve balance and stability, reducing the risk of falls. However, it’s important that the cane is used correctly and is the right height for the individual.
Choice C rationale
Unsecured throw rugs, especially over a slippery surface like a tile floor, can easily cause someone to slip and fall. It’s recommended to secure rugs with non-slip backing or remove them entirely from high-traffic areas.
Choice D rationale
Macular degeneration can lead to vision loss, which can increase the risk of falls. Individuals with vision impairments may not be able to see hazards in their path, making them more prone to falls.

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Correct Answer is D

Explanation

Choice A rationale
Skeletal muscles do not enable the heart to contract with each heartbeat. The heart has its own specialized muscle tissue known as cardiac muscle, which allows it to contract and pump blood throughout the body.
Choice B rationale
Skeletal muscles do not enable the bladder to contract during voiding. The detrusor muscle, a smooth muscle found in the wall of the bladder, contracts during urination to expel urine from the body.
Choice C rationale
Skeletal muscles do not enable the bronchioles to dilate in the lungs. The dilation and constriction of the bronchioles are controlled by the autonomic nervous system and the smooth muscles in the walls of the bronchioles.
Choice D rationale
Skeletal muscles do enable a hand to contract and form a fist. Skeletal muscles are responsible for all voluntary movements, including making a fist. When you want to make a fist, your brain sends a signal to the skeletal muscles in your hand and forearm, telling them to contract. This pulls on the tendons connected to your fingers, causing them to move and form a fist.

A. You will have a steady and gradual decline in function. B. You must avoid stress and extreme fatigue because it can trigger a relapse. C. Your type of multiple sclerosis is the least common, making it difficult to manage. D. You should take your medications only during times of relapse.

Correct Answer is B

Explanation

Choice A rationale
This statement is not accurate. Relapsing-remitting multiple sclerosis (RRMS) is characterized by periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These episodes are followed by periods of remission, where the disease does not progress. Therefore, RRMS does not cause a steady and gradual decline in function.
Choice B rationale
This is the correct answer. Stress and extreme fatigue can trigger a relapse in RRMS1. Therefore, it is important for patients to avoid these triggers to manage their symptoms effectively.
Choice C rationale
This statement is incorrect. RRMS is the most common disease course at the time of diagnosis. It is not the least common type of multiple sclerosis.
Choice D rationale
This statement is not accurate. Medications for RRMS, known as disease-modifying treatments (DMT), are designed to reduce the frequency and severity of relapses. They are not intended to be taken only during times of relapse, but rather on an ongoing basis to manage the disease.

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A nurse is reviewing a fall risk assessment for a client. Which of the following findings place the client at risk for a fall? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.