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 D

Explanation

A) A client who has heart failure and peripheral edema:
While heart failure and peripheral edema are significant conditions that require medical attention, they are chronic issues that, in most cases, are not immediately life-threatening in an emergency department setting unless there is acute decompensated heart failure or signs of severe fluid overload or respiratory distress.

B) A client who reports urinary burning and a temperature of 29.2° C (102.5°F):
This client is febrile, which suggests an infection, possibly a urinary tract infection (UTI). Although fever and urinary burning are concerning, infection-related fevers generally don't pose an immediate life threat unless there is sepsis or severe systemic involvement. A temperature of 102.5°F is significant, but the client's condition is not as urgent as other life-threatening emergencies like an arrhythmia or severe cardiovascular instability.

C) A client who has cirrhosis of the liver and bruising on their arms:
Bruising in a client with cirrhosis of the liver could indicate bleeding tendencies, which is an important concern. However, unless there is active bleeding or signs of severe liver failure (e.g., confusion, ascites, jaundice), this is not an immediate, life-threatening situation.

D) A client who has a new onset of atrial fibrillation and a heart rate of 152/min:
A new onset of atrial fibrillation (AF) with a heart rate of 152/min is an immediate priority. This is a life-threatening arrhythmia that can lead to decreased cardiac output, risk of stroke, and hemodynamic instability. A heart rate of 152 beats per minute is dangerously high, which could lead to tachycardia-induced cardiomyopathy or cardiogenic shock. Immediate intervention is needed to manage the arrhythmia and prevent further complications.

A. Apply pressure to the client’s nasolacrimal duct after instillation B. Clean the client's eye from the outer canthus to the inner canthus before instillation C. Ask the client to tightly squeeze their eyes shut after the instillation D. Instill the ophthalmic medication directly on the client's cornea.

Correct Answer is A

Explanation

A) Apply pressure to the client’s nasolacrimal duct after instillation:
Applying gentle pressure to the nasolacrimal duct after administering an ophthalmic medication is a recommended practice. This action prevents the medication from draining into the nasopharynx, reducing the risk of systemic absorption and minimizing potential side effects. It also helps ensure that the medication stays localized in the eye for maximum therapeutic effect. This technique is especially important for medications like eye drops that could otherwise be absorbed systemically, such as those for glaucoma treatment.

B) Clean the client's eye from the outer canthus to the inner canthus before instillation:
The correct procedure for cleaning the eye prior to instilling ophthalmic medication is to clean from the inner canthus (near the nose) to the outer canthus (toward the temple). This technique avoids dragging debris from the outer eye toward the sensitive inner corner and helps prevent introducing contaminants into the eye. Cleaning from outer to inner canthus could potentially push debris toward the tear ducts and further irritate the eye.

C) Ask the client to tightly squeeze their eyes shut after the instillation:
Asking the client to tightly squeeze their eyes shut after instillation is not recommended. Squeezing the eyes shut can increase intraocular pressure and may actually force the medication out of the eye, reducing its effectiveness. Instead, the client should be encouraged to gently close their eyes and avoid blinking excessively. This allows the medication to stay in contact with the eye for a longer period.

D) Instill the ophthalmic medication directly on the client's cornea:
Instilling ophthalmic medication directly on the cornea is not recommended. The correct technique is to instill the medication into the conjunctival sac, which is the space between the lower eyelid and the eyeball. Instilling the medication directly onto the cornea could lead to irritation, discomfort, or damage to the sensitive corneal surface, and it would not allow the medication to be absorbed as intended.

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