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. "The medication may cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of haloperidol. This statement does not indicate understanding of the medication’s typical side effects.
B. "The medication may cause urinary incontinence.": Urinary incontinence is not a common side effect of haloperidol. This statement is not accurate regarding the medication's effects.
C. "I may be more sensitive to the sun while taking this medication.": This statement indicates understanding, as haloperidol can increase sensitivity to sunlight, making clients more susceptible to sunburn.
D. "I may experience a metallic taste while taking this medication.": A metallic taste is not a common side effect of haloperidol. This statement does not reflect the typical effects of the medication.

A. Orthostatic hypotension increases a client's risk of a fall. B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. C. Orthostatic hypotension increases a client's risk of a pulmonary emboli D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Correct Answer is A

Explanation

A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.

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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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Naxlex Comprehensive Predictor Exams

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