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 A

Explanation

Choice A rationale
Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.

A. Lower systolic blood pressure B. Reduced bladder capacity C. Increased difficulty seeing due to heightened sensitivity to glare D. Dehydration of intervertebral discs E. Reduced cough reflex

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale
As people age, the stiffness of the arterial system increases, leading to left ventricle hypertrophy, increased afterload on the left ventricle, and an increase in systolic blood pressure. This is a physiological change that occurs with aging.
Choice B rationale
With aging, the number of cells in the kidneys decreases markedly, which can affect the functioning of the urinary tract, including the bladder. This can lead to a reduced bladder capacity.
Choice C rationale
This statement is incorrect. As people age, they often experience a decrease in visual acuity and an increased sensitivity to glare. This can make it more difficult for older adults to see, especially in brightly lit environments.
Choice D rationale
Dehydration of intervertebral discs is a common occurrence with aging. This can lead to a decrease in height and changes in the curvature of the spine.
Choice E rationale
As people age, their cough reflex can become reduced. This can increase the risk of aspiration and pneumonia, especially in individuals with other health conditions that affect swallowing.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

Correct Answer is A

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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.