A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Inguinal hernia

Hyperlipidemia

Multiple sclerosis

Hyperthyroidism

Answer and Explanation

The Correct Answer is C

A. Inguinal hernia: While an inguinal hernia can cause discomfort and might require surgical intervention, it is not a primary risk factor for falls compared to other conditions.
B. Hyperlipidemia: Elevated lipid levels are primarily a risk factor for cardiovascular issues and do not directly affect balance or mobility, making it less relevant as a fall risk.
C. Multiple sclerosis: This condition affects the central nervous system and can lead to muscle weakness, balance issues, and coordination problems, increasing the risk of falls.
D. Hyperthyroidism: While hyperthyroidism can have various health effects, it does not directly contribute to fall risk as significantly as multiple sclerosis does.

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Correct Answer is ["A","C","E"]

Explanation

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

A. Placing a pad under the patient's head after guiding them to the floor from a standing position B. Avoiding placing any objects in the mouth when the patient's teeth are clenched C. Guiding the patient to the bed from the floor during a seizure D. Turning the patient to one side, having a slightly forward-tilted head E. Using supporting pillows for the patient who is on bed

Correct Answer is ["A","B","D","E"]

Explanation

A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.

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A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select All that Apply)

Correct Answer is ["A","C","E"]

Explanation

Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

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