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","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.

A. Ask the client to demonstrate walking with the cane. B. Show the client a video about walking with a cane. C. Identify short-term goals for the client. D. Determine the client's readiness to learn.

Correct Answer is A

Explanation

A. Ask the client to demonstrate walking with the cane: Correct. Evaluation involves assessing the client’s ability to perform the learned skill, which is done by asking the client to demonstrate walking with the cane.
B. Show the client a video about walking with a cane: This is part of the teaching process, not evaluation. It is used to provide information but does not assess the client's understanding or ability.
C. Identify short-term goals for the client: This is part of the planning stage, where goals are set to guide the teaching and learning process, not part of evaluation.
D. Determine the client's readiness to learn: This is an initial assessment step before teaching begins, not part of the evaluation process after teaching has occurred.

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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

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

A nurse is preparing a teaching plan for a client who is learning to walk with a cane. The nurse should identify that which of the following actions is a evaluation step of the teaching plan?

Correct Answer is A

Explanation

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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A nurse is teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor?