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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?

A.

Inguinal hernia

B.

Hyperlipidemia

C.

Multiple sclerosis

D.

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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Related Questions

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

Explanation

A. Provide educational material written at an eighth-grade reading level: Educational material should be understandable to the client, and an eighth-grade reading level is typically accessible for most individuals.
B. Turn on the television in the client's room: Turning on the television can be distracting and is not conducive to effective preoperative teaching.
C. Use technical language in the educational session: Technical language can be confusing for clients; plain language should be used to ensure understanding.
D. Start with the most important information: Prioritizing the most critical information ensures that the client understands essential aspects of their procedure, even if they cannot retain all details.

Correct Answer is D

Explanation

A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.

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