A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
A client with diabetes mellitus who has a leg ulcer
An adolescent client who has a leg fracture and has been using crutches for the past 2 days
An older adult client who is confused and has urinary frequency
A client who is 1 day postoperative and has a nursing assistant helping him out of bed
The Correct Answer is C
A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Increasing the intake of high-fiber foods, not low-fiber ones, as fiber helps to soften stools and promote bowel movements.
B. Drinking warm or hot liquids can stimulate bowel movements, so they should not be avoided.
C. Including probiotic foods in the diet can help maintain a healthy gut flora, which is beneficial for digestion and preventing constipation.
D. It is crucial to increase fluid intake, aiming for at least 1500 mL daily, to help soften the stool and support regular bowel movements.
E. Increasing daily exercise, especially walking, can stimulate the muscles involved in the digestive process and help prevent constipation.
Correct Answer is A
Explanation
A. Daily antihistamines can help control itching associated with atopic dermatitis.
B. Solid carbon dioxide is not used to treat atopic dermatitis.
C. Mouth cleansing is not relevant for atopic dermatitis, which primarily affects the skin.
D. Antibiotics are not typically used for atopic dermatitis unless there is a secondary bacterial infection.
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