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 B

Explanation

Choice A rationale
While tremors and decreased mobility are common symptoms of Parkinson’s disease, they are not the most significant impact on a patient’s life. These physical symptoms can be managed with medication and physical therapy.
Choice B rationale
Loss of independence is often the most significant impact on a patient’s life. As the disease progresses, patients may find it increasingly difficult to perform daily activities and may require assistance.
Choice C rationale
Age-related changes can contribute to the progression of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The disease itself, rather than aging, is the primary cause of the symptoms.
Choice D rationale
Neurologic deficits are a result of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The loss of independence that results from these deficits is often more impactful.

A. Slow capillary refill B. Ringing in the ears C. Cold hands and feet D. Mottled and blotchy skin, especially on the hands, feet, and knees

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale
Slow capillary refill is a sign that the body is not circulating blood as effectively as it should be. This can be a sign that a person is actively dying.
Choice B rationale
Ringing in the ears, also known as tinnitus, is not typically a sign that a person is actively dying. It can be caused by a variety of factors, including exposure to loud noise, certain medications, and some health conditions.
Choice C rationale
Cold hands and feet can be a sign that a person is actively dying. As the body’s systems start to shut down, blood flow to the extremities can decrease, causing them to feel cold.
Choice D rationale
Mottled and blotchy skin, especially on the hands, feet, and knees, can be a sign that a person is actively dying. This is caused by reduced blood flow to the skin.

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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

Correct Answer is B

Explanation

Select physical signs you may see in a patient who is actively dying.

Correct Answer is ["A","C","D"]

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.