The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Balance

Stride

Flexibility

Speed

Answer and Explanation

The Correct Answer is A

A. Balance:

The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.

B. Stride:

Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.

C. Flexibility:

While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.

D. Speed:

Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.

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Correct Answer is B

Explanation

A. Age-related motor deficiencies that result in self-neglect.

Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.

B. Age-related neurosensory changes that diminish awareness of temperature changes.

Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.

C. Delirium related to an acute illness that is affecting body heat production.

Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.

D. Cognitive changes that diminish the individual's awareness of temperature changes.

Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.

A. Decreased serum albumin levels B. Decreased vitamin D levels C. Unintentional weight loss, D. Anorexia lasting more than 24 hours

Correct Answer is C

Explanation

A. Decreased serum albumin levels.

Explanation: Decreased serum albumin levels can be an indicator of poor nutritional status, but they are not as immediate or easily observed as unintentional weight loss.

B. Decreased vitamin D levels.

Explanation: Decreased vitamin D levels may indicate a specific nutrient deficiency but may not capture the overall nutritional status comprehensively.

C. Unintentional weight loss.

Explanation: Unintentional weight loss is a significant indicator of potential nutritional deficits and can be associated with underlying health issues. It can lead to deficiencies in essential nutrients, negatively impacting an individual's overall health and well-being. Weight loss should prompt further assessment and intervention to identify the underlying causes and address nutritional needs

D. Anorexia lasting more than 24 hours.

Explanation: Anorexia (loss of appetite) lasting more than 24 hours may contribute to inadequate nutrient intake, but it is not as direct an indicator as unintentional weight loss, which reflects changes in body composition and overall nutritional status.

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The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

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Naxlex Comprehensive Predictor Exams

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

Correct Answer is B

Explanation

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

Correct Answer is C

Explanation

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