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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Because a conservatorship is the least restrictive alternative, a court hearing is not required.
Explanation: This statement is not accurate. Conservatorships are legal arrangements that involve the appointment of a conservator to manage the financial affairs and assets of an individual who is unable to do so themselves. While conservatorships may be necessary for the protection of the individual, they are not automatically considered the least restrictive alternative, and a court hearing is typically required to establish one.
B. The most legally restricting way individuals and property can be handled are through conservatorships and guardianships.
Explanation: This statement is partially true. Conservatorships and guardianships are legal mechanisms that grant authority to individuals (conservators and guardians, respectively) to manage the affairs of someone who is unable to do so themselves. While they involve legal restrictions, whether they are the most restrictive or not can depend on the specific details of the arrangement and the jurisdiction.
C. A conservatorship entails control over property, whereas a guardianship entails control over the person.
Explanation: This statement is true. In general, a conservatorship focuses on managing the financial affairs and assets of an individual, while a guardianship involves decision-making authority over personal and healthcare matters. The roles and responsibilities of conservators and guardians may vary by jurisdiction, but the distinction between control over property and control over the person is a common principle.
D. Conservators cannot be members of the conservatee's (client's) family.
Explanation: This statement is not universally true. In many cases, family members can be appointed as conservators. The court will typically consider the best interests of the individual in need of protection when appointing a conservator, and a family member may be deemed suitable if they can fulfill the responsibilities of the role. The specific rules regarding who can be a conservator may vary by jurisdiction.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water.
Explanation: Using cool or tepid water for activities like sponge baths or cool compresses can help lower body temperature and provide relief from heat.
B. Avoid alcohol.
Explanation: Alcohol can contribute to dehydration. Advising the client to avoid alcohol helps maintain proper hydration levels, which is crucial in preventing hyperthermia.
C. Minimize exertion.
Explanation: Excessive physical exertion in high temperatures can lead to overheating. Advising the client to minimize physical activity during peak heat hours can help prevent hyperthermia.
D. Wear cool clothing such as silk or polyester.
Explanation: Light and breathable fabrics like silk or polyester can assist in keeping the body cool by allowing better air circulation. This helps prevent overheating.
E. Drink plenty of fluids.
Explanation: Staying well-hydrated is essential in preventing hyperthermia. Encouraging the client to drink plenty of fluids helps maintain hydration and regulate body temperature.
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