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 D
Explanation
Choice A rationale
Skeletal muscles do not enable the heart to contract with each heartbeat. The heart has its own specialized muscle tissue known as cardiac muscle, which allows it to contract and pump blood throughout the body.
Choice B rationale
Skeletal muscles do not enable the bladder to contract during voiding. The detrusor muscle, a smooth muscle found in the wall of the bladder, contracts during urination to expel urine from the body.
Choice C rationale
Skeletal muscles do not enable the bronchioles to dilate in the lungs. The dilation and constriction of the bronchioles are controlled by the autonomic nervous system and the smooth muscles in the walls of the bronchioles.
Choice D rationale
Skeletal muscles do enable a hand to contract and form a fist. Skeletal muscles are responsible for all voluntary movements, including making a fist. When you want to make a fist, your brain sends a signal to the skeletal muscles in your hand and forearm, telling them to contract. This pulls on the tendons connected to your fingers, causing them to move and form a fist.
Correct Answer is A
Explanation
Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.
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