Exhibits

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

WBC Count

Parkinson’s disease

Potassium level on day 2

Furosemide

Low blood pressure

Answer and Explanation

Correct Answer : B,C,D,E

Choice A: WBC Count

Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.

Choice B: Parkinson’s disease

Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.

Choice C: Potassium level on day 2

Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.

Choice D: Furosemide

Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.

Choice E: Low blood pressure

Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.

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Free Nursing Study Resources

Correct Answer is ["15"]

Explanation

Step 1: Determine the dosage available per mL.

The available dosage is 75 mg per 5 mL.
To find the dosage per mL, divide 75 mg by 5 mL.
75 mg ÷ 5 mL = 15 mg/mL.
Result: 15 mg/mL.

Step 2: Determine how many mL are needed for the prescribed dose.

The prescribed dose is 225 mg.
To find the required mL, divide 225 mg by the dosage per mL (15 mg/mL).
225 mg ÷ 15 mg/mL = 15 mL.
Result: 15 mL.

So, the nurse should administer 15 mL of clindamycin palmitate oral suspension every 8 hours.

A. Botulism is acquired through direct contact with an infected person. B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed. C. Botulism can produce paralysis within 12 to 72 hours following exposure. D. Vomiting and diarrhea are expected findings following exposure. E. Botulism is a toxin found in castor beans.

Correct Answer is ["C"]

Explanation

Choice A: Botulism is Acquired Through Direct Contact with an Infected Person

Botulism is not acquired through direct contact with an infected person. It is caused by a toxin produced by the bacterium Clostridium botulinum. The most common forms of botulism are foodborne, wound, and infant botulism. Foodborne botulism occurs when a person ingests food containing the toxin, while wound botulism occurs when the bacteria infect a wound and produce the toxin. Infant botulism occurs when infants ingest spores of the bacteria, which then grow and produce the toxin in their intestines.

Choice B: Notify the Centers for Disease Control and Prevention (CDC) When More Than Three Cases Are Confirmed

While notifying the CDC is crucial in the event of a botulism outbreak, the specific threshold for notification can vary. Generally, any suspected case of botulism should be reported to public health authorities immediately due to the severity of the disease and the potential for outbreaks. The CDC provides guidelines for reporting and managing botulism cases.

Choice C: Botulism Can Produce Paralysis Within 12 to 72 Hours Following Exposure

Botulism can indeed produce paralysis within 12 to 72 hours following exposure. The toxin affects the nervous system, leading to muscle paralysis. Early symptoms include weakness, dizziness, and dry mouth, followed by more severe symptoms such as blurred vision, difficulty swallowing, and muscle weakness. If left untreated, botulism can lead to respiratory failure and death.

Choice D: Vomiting and Diarrhea Are Expected Findings Following Exposure

Vomiting and diarrhea are not typical symptoms of botulism. The primary symptoms are related to muscle paralysis and neurological impairment. Gastrointestinal symptoms may occur in some cases of foodborne botulism, but they are not the hallmark signs of the disease.

Choice E: Botulism is a Toxin Found in Castor Beans

Botulism is not a toxin found in castor beans. The toxin found in castor beans is ricin, which is a different type of bioterrorism agent. Botulism is caused by the botulinum toxin produced by Clostridium botulinum bacteria.

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Exhibits A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply

Choice A: WBC Count

Choice B: Parkinson’s disease

Choice C: Potassium level on day 2

Choice D: Furosemide

Choice E: Low blood pressure

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["15"]

Explanation

A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)

Correct Answer is ["C"]

Explanation

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Exhibits

A nurse is performing a fall risk assessment on a patient. Which of the following findings indicate that the patient is at increased risk for falls? Select all that apply