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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The goal of hospice care is to prolong life: Hospice care focuses on providing comfort and improving quality of life rather than prolonging life. It is aimed at managing symptoms and supporting patients and families when a cure is no longer possible.
B. Hospice care is limited to clients who are in a health care facility: Hospice care can be provided in various settings, including the patient's home, nursing homes, or hospice facilities. It is not limited to health care facilities.
C. Hospice care is restricted to clients who are terminally ill: Hospice care is specifically designed for individuals who are terminally ill, typically with a prognosis of 6 months or less to live if the disease runs its usual course. This ensures the care is appropriate and focused on end-of-life comfort.
D. Hospice care cannot be discontinued once it is initiated: Hospice care can be discontinued if the patient's condition improves or if they decide to pursue curative treatment. It is not a permanent commitment.
Correct Answer is A
Explanation
A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.
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