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 ["B","D","E"]
Explanation
A. Urine-specific gravity greater than 1.030 indicates concentrated urine, suggesting dehydration, not fluid volume excess.
B. A bounding pulse is a sign of fluid volume excess.
C. Swelling at the IV site indicates infiltration, not systemic fluid volume excess.
D. Crackles upon auscultation of the lungs indicate fluid accumulation in the lungs, a sign of fluid volume excess.
E. Pitting edema is a sign of fluid volume excess, indicating fluid retention in the tissues.
Correct Answer is A
Explanation
A. Liver function tests are necessary before starting atorvastatin due to the medication's potential for hepatotoxicity.
B. Papanicolaou test is not specifically required before starting atorvastatin; it is used for cervical cancer screening.
C. Dental examination is not typically required before starting atorvastatin unless indicated for other reasons.
D. Hearing test is not specifically required before starting atorvastatin; it is usually assessed based on symptoms or clinical indication.
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