An older adult comes to the emergency department after falling at home, and reports "I can't walk without losing my balance." Which steps should the nurse implement for this client?
Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion.
Determine symptom onset or when the fall occurred.
Arrange for a transfer immediately to the radiology department.
Perform a comprehensive neurologic assessment.
None of the above.
The Correct Answer is D
Choice A reason: Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion is not the appropriate step, as it is a treatment for acute ischemic stroke, which has not been confirmed in this client. tPA is a clot-busting drug that can restore blood flow to the brain, but it has strict criteria and time window for its use. The nurse should not assume that the client has a stroke without further assessment and diagnosis.
Choice B reason: Determine symptom onset or when the fall occurred is not the appropriate step, as it is not the priority for this client. The nurse should first assess the client's vital signs, neurologic status, and potential injuries from the fall. The symptom onset or fall time may be relevant for the diagnosis and treatment of the underlying cause, but it is not the most urgent information to obtain.
Choice C reason: Arrange for a transfer immediately to the radiology department is not the appropriate step, as it is not the most immediate intervention for this client. The nurse should first stabilize the client's condition, perform a thorough assessment, and obtain orders from the medical provider. The radiology department may be needed for diagnostic tests, such as computed tomography (CT) scan or magnetic resonance imaging (MRI), but it is not the first destination for this client.
Choice D reason: Perform a comprehensive neurologic assessment is the appropriate step, as it can help identify the possible cause of the client's balance problem and rule out a stroke or other serious condition. A neurologic assessment includes checking the client's level of consciousness, orientation, speech, cranial nerve function, motor strength, sensory perception, coordination, and reflexes. The nurse should also monitor the client's vital signs, oxygen saturation, and blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Health equity is not the definition of health disparity, but rather the opposite of it. Health equity is the state of fair and equal opportunity for everyone to achieve optimal health, regardless of social or economic factors.
Choice B reason: The difference between an expected incidence and prevalence and that which actually occurs in a comparison population group is not the definition of health disparity, but rather a way of measuring it. Incidence and prevalence are epidemiological terms that refer to the number of new and existing cases of a disease or condition in a population, respectively.
Choice C reason: The systematic elimination of the culture of another resulting in decreased wellness is not the definition of health disparity, but rather an example of cultural genocide. Cultural genocide is the deliberate destruction of the identity, heritage, or traditions of a group of people.
Choice D reason: Differences in health outcomes between groups is the definition of health disparity, as it describes the situation where some groups of people experience worse health status or quality of life than others, due to factors such as race, ethnicity, gender, income, education, or geography.
Correct Answer is B
Explanation
Choice A: The use of restraints on older patients helps prevent injuries from falls - This statement is not true. The use of restraints can increase the risk of injury and is generally discouraged¹.
Choice B: About 50% to 70% of falls in hospitals occur while transferring between bed and chair - This statement is true. Transfers are a high-risk activity for falls, and appropriate precautions should be taken¹.
Choice C: Falls that do not cause physical injury are not significant - This statement is not true. Even falls without injury can have significant psychological impacts, leading to fear of falling and reduced mobility¹.
Choice D: The get-up-and-go test provides a measure of a patient's energy and initiative - This statement is not true. The get-up-and-go test is used to assess a person's mobility and balance, not their energy and initiative¹.
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