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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale
Neurogenic bladder is a condition where a person lacks bladder control due to a brain, spinal cord or nerve condition. This is not the most fitting answer because the scenario does not provide information about any neurological conditions.
Choice B rationale
Urinary retention can lead to urinary tract infections. The retained urine provides a breeding ground for bacteria, which can lead to infection.
Choice C rationale
Bladder outlet obstruction is a condition where the bladder is not able to empty properly. While urinary retention could be a symptom of this condition, the scenario does not provide enough information to suggest this diagnosis.
Choice D rationale
Genitourinary System Effects is a broad term that refers to any effects on the genital and urinary systems. This is not the most fitting answer because it is less specific than Choice B2.
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