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 C

Explanation

A: This option is incorrect because the date is wrong, and it uses "TOJ" which is not a standard abbreviation in medical documentation. The correct format should include the date the order was received, the medication and dosage, frequency, reason for administration, and the initials of the person taking the order along with a 'read back' confirmation.
B: This choice is incorrect because it lacks the 'read back' confirmation which is a critical part of telephone orders to ensure accuracy. Additionally, the use of "TOJ" is incorrect, and the date format is inconsistent with standard medical records.
C: This is the correct choice because it includes all necessary information: the correct date, medication and dosage, frequency, reason for administration, and it correctly identifies the order as a telephone order with "TO" followed by the doctor's name, and includes the nurse's initials with a 'read back' confirmation.
D: This option is incorrect because it uses "VO" which stands for verbal order, not a telephone order. It also lacks the full date and has an inconsistent date format. The 'read back' confirmation is present, but the incorrect order type makes this entry invalid.

A. Compassion fatigue B. Adventitious stress C. Prolonged grief disorder D. Post-traumatic stress disorder (PTSD)

Correct Answer is A

Explanation

A. Compassion fatigue: Correct. Compassion fatigue is characterized by emotional exhaustion and a reduced ability to empathize due to prolonged exposure to others' suffering, which fits the nurse’s experience of feeling overwhelmed and difficulty feeling sympathy.
B. Adventitious stress: Incorrect. Adventitious stress refers to stress caused by external, unexpected events such as natural disasters or accidents, not by ongoing exposure to clients' suffering.
C. Prolonged grief disorder: Incorrect. Prolonged grief disorder involves intense and persistent grief following a loss, not the emotional exhaustion or empathy issues described by the nurse.
D. Post-traumatic stress disorder (PTSD): Incorrect. PTSD is characterized by severe anxiety, flashbacks, and intrusive thoughts related to trauma, not primarily by empathy fatigue or feeling overwhelmed by others' suffering.

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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?

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