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","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.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
High glucose levels can indicate uncontrolled diabetes, which can increase the risk of surgical complications such as infection and poor wound healing.
Choice B rationale
Metformin is a medication used to treat type 2 diabetes. It can increase the risk of lactic acidosis, especially in patients undergoing procedures that involve the use of contrast dye.
Choice C rationale
A history of smoking can increase the risk of surgical complications, including poor wound healing, infection, and lung problems.
Choice D rationale
An elevated white blood cell (WBC) count can indicate an infection or inflammation in the body, which can increase the risk of surgical complications.
Choice E rationale
Type 2 diabetes mellitus can increase the risk of surgical complications, including infection, poor wound healing, and cardiovascular complications.
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