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 B

Explanation

A. The goal of palliative care is to prolong the life of a client: The primary goal of palliative care is to improve the quality of life by alleviating symptoms and providing support, rather than specifically prolonging life.
B. Palliative care is not restricted to clients who are terminally ill: Palliative care can be provided to any client with a serious illness, regardless of the stage of their condition. It focuses on comfort and quality of life rather than just end-of-life care.
C. Palliative care should be avoided for a client who is receiving a cure: Palliative care is not mutually exclusive with curative treatment. It can be provided alongside curative therapies to manage symptoms and improve the client’s quality of life.
D. Palliative care is limited to clients who are in a health care facility: Palliative care can be provided in various settings, including at home, in outpatient clinics, and in healthcare facilities. It is not restricted to any particular location.

A. Use soap and water to clean the client's perineum. B. Use the same section of washcloth for each area cleaned. C. Allow the client's perineum to air dry. D. Start at the client's rectum and clean to the client's perineum.

Correct Answer is A

Explanation

A. Use soap and water to clean the client's perineum: Correct. Using soap and water is the standard method for cleaning the perineum to ensure it is effectively cleaned while maintaining hygiene.
B. Use the same section of washcloth for each area cleaned: Incorrect. To prevent cross-contamination, the nurse should use a clean section of the washcloth or a new washcloth for each area cleaned.
C. Allow the client's perineum to air dry: Incorrect. The perineum should be gently patted dry with a clean towel to prevent irritation and ensure proper drying.
D. Start at the client's rectum and clean to the client's perineum: Incorrect. The proper technique is to clean from the perineum to the rectum to prevent the spread of bacteria from the rectal area to the vaginal area.

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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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