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 ["A","B","C","D"]

Explanation

A. Making refreshment stations readily available

Explanation: Making refreshment stations readily available can encourage individuals with dementia to access snacks and beverages independently. This can help ensure a consistent intake of calories and nutrients throughout the day.

B. Caloric supplements with the meals

Explanation: Caloric supplements can provide additional nutrients and energy, especially if the client has difficulty consuming an adequate amount of food during meals. Consultation with a healthcare professional is recommended to determine the appropriate type and amount of supplements.

C. Providing feeding assistance

Explanation: Offering feeding assistance, such as help with cutting food into manageable pieces or providing cueing and encouragement during meals, can support individuals with dementia in maintaining proper nutrition.

D. Optimal social supports

Explanation: Optimal social supports, including family members, caregivers, or support groups, can play a crucial role in monitoring the nutritional status of individuals with dementia. Social interactions during meals can positively impact eating behaviors, and caregivers can provide assistance and encouragement.

A. Encouraging the client to use a cane wien ambulating B. Keeping the side rails up on the client's bed at night C. keeping several low wattage night lights crin in the evening D. Installing wooden railings on the stairway to the bathroom

Correct Answer is B

Explanation

A. Encouraging the client to use a cane when ambulating.

Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.

B. Keeping the side rails up on the client's bed at night.

Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.

C. Keeping several low wattage night lights on in the evening.

Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.

D. Installing wooden railings on the stairway to the bathroom.

Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.

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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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