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

Explanation

A. Dual diagnosis treatment: This group is appropriate as it addresses both the antisocial personality disorder and alcohol dependency. Dual diagnosis treatment provides integrated care for individuals with co-occurring mental health and substance use disorders, making it a suitable option for this client.
B. Codependency support: This group primarily focuses on individuals affected by another person's substance use or behavior rather than directly addressing the issues of substance dependence and personality disorders in the individual.
C. Psychodrama: While psychodrama can be useful for exploring interpersonal issues and emotional experiences, it may not specifically address the dual challenges of antisocial personality disorder and alcohol dependency as effectively as dual diagnosis treatment.
D. Crisis intervention: This group focuses on immediate problems and crisis management rather than ongoing management of complex, co-occurring disorders. It may not provide the comprehensive support needed for both antisocial personality disorder and alcohol dependency.

A. Clean hands with soap and water after caring for the client B. Place the client in a room with negative pressure airflow C. Wash hands for 10 seconds after caring for the client D. Apply a mask on the client when they are outside their room

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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