A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

Electrical cord on floor over a walkway

Demonstrates correct use of cane to ambulate

Grab bar in the bathroom

Diagnosis of Macular degeneration

Throw rugs in kitchen

Answer and Explanation

Correct Answer : A,D,E

A. Electrical cord on floor over a walkway:
An electrical cord on the floor in a walkway poses a significant tripping hazard. Clients may not notice the cord or may have difficulty stepping over it, increasing the risk of falls, particularly for individuals with impaired mobility or vision.

B. Demonstrates correct use of cane to ambulate:
Proper use of a cane improves balance and stability, reducing fall risk rather than contributing to it. Clients who demonstrate correct usage are actively minimizing their likelihood of falling.

C. Grab bar in the bathroom:
Grab bars provide added support and stability, particularly in areas prone to slips, such as bathrooms. Their presence is a preventive measure rather than a fall risk.

D. Diagnosis of Macular degeneration:
Macular degeneration impairs central vision, which can lead to difficulties in detecting obstacles and maintaining balance, increasing the client’s susceptibility to falls.

E. Throw rugs in kitchen:
Throw rugs are a well-documented fall hazard because they can slip, bunch up, or create uneven surfaces. They are particularly risky for older adults and those with mobility impairments.

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Correct Answer is B

Explanation

A) The client is underweight:
Being underweight is not directly associated with an increased risk of incisional hematoma formation. However, underweight individuals may have a lower amount of subcutaneous fat, which could affect wound healing. While nutritional status plays a role in recovery after surgery, being underweight does not specifically increase the risk of hematoma formation at
the incision site.

B) The client takes anticoagulant medications:
Taking anticoagulant medications (e.g., warfarin, heparin, or newer anticoagulants like dabigatran) increases the risk of bleeding and the formation of an incisional hematoma. Anticoagulants work by reducing the blood's ability to clot, making it more difficult to stop bleeding after surgery. This increases the likelihood of blood accumulating in the tissue around the incision site, potentially forming a hematoma.

C) The client has urinary incontinence:
Urinary incontinence does not directly increase the risk of incisional hematoma formation. However, it can lead to other complications, such as skin irritation or infection, but it is not a primary risk factor for hematoma formation in the surgical wound. The main concern with urinary incontinence in the perioperative period is ensuring proper skin care to prevent moisture-associated skin damage.

D) The client has peripheral vascular disease:
Peripheral vascular disease (PVD) affects circulation in the extremities, which can impair wound healing due to decreased blood flow. While PVD can contribute to delayed healing and complications like infection, it is not the most significant factor for the formation of incisional hematomas.

A. They bend at the ho when lifting. B. They keep their feet together when »tins an object C. They stand chose to the object being, moved D. They twist their spine when lifting

Correct Answer is C

Explanation

A) They bend at the ho when lifting:
This statement seems to be a typographical error, but it likely refers to "bending at the hips" when lifting. While bending at the hips can help reduce strain on the back, it is not the ideal body mechanic for lifting heavy objects. Proper lifting techniques involve bending at the knees, not the hips, to maintain proper alignment and reduce the risk of injury to the lower back. The correct form would be to squat down using the legs and keeping the back straight.

B) They keep their feet together when lifting an object:
Keeping the feet together when lifting an object is not advisable. The nurse should keep their feet shoulder-width apart for stability when lifting heavy objects. This wide stance provides a stable base and helps prevent loss of balance or strain during the lift. Keeping feet together would increase the risk of losing balance and possibly causing injury.

C) They stand close to the object being moved:
Standing close to the object being moved is the correct body mechanic. When lifting, the nurse should position themselves close to the object to minimize the leverage needed to lift it. By maintaining a short distance from the object, the nurse can use their legs to lift rather than relying on their back, which helps reduce the risk of back strain or injury.

D) They twist their spine when lifting:
Twisting the spine when lifting is a dangerous action that increases the risk of back injury. Proper body mechanics require that the nurse keep the back straight and avoid twisting the spine during the lift. Instead, they should rotate their whole body, moving their feet to turn, rather than twisting the spine. Twisting puts unnecessary stress on the spinal discs and can lead to muscle strain or injury.

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A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply,

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Correct Answer is C

Explanation

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