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
Academic pressure is a psychological stressor, not a physiological one. It involves mental or emotional strain or tension resulting from adverse or demanding circumstances, in this case, related to academic performance.
Choice B rationale
A burn injury is an example of a physiological stressor. Physiological stressors are related to physical or biological factors that strain the body’s resources. A burn injury places physical stress on the body as it tries to heal and recover.
Choice C rationale
Financial difficulties are a type of environmental stressor, not a physiological one. They involve external factors in a person’s environment that cause stress, such as financial problems or jobrelated stress.
Choice D rationale
A change in marital status is a type of psychosocial stressor, not a physiological one. It involves both psychological factors (such as emotions and behavior) and social factors (such as relationships and social interactions).

A. A perceived stressor stimulates the central nervous system. B. The body remains alert, while blood pressure and heart rate return to pre-stress levels. C. Prolonged exposure to stress can result in illness. D. An increase in hormones causes an increase in blood pressure and heart rate.

Correct Answer is A

Explanation

Choice A rationale
The first physiological response that occurs during the General Adaptation Syndrome (GAS) is
the alarm reaction stage. This stage is the body’s initial response to stress, where the sympathetic nervous system is activated by the sudden release of hormones.
Choice B rationale
The body remaining alert while blood pressure and heart rate return to pre-stress levels is part of the resistance stage of GAS, not the first physiological response.
Choice C rationale
Prolonged exposure to stress resulting in illness is associated with the exhaustion stage of GAS, which is the final stage, not the first physiological response.
Choice D rationale
An increase in hormones causing an increase in blood pressure and heart rate is part of the alarm reaction stage, but it is not the first physiological response. The first response is the perception of a stressor that stimulates the central nervous system.

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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

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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.