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

Explanation

A. Sub-acute care is more intensive than traditional nursing home care.

Explanation: Sub-acute care is generally more intensive and focused on providing specialized, short-term medical care and rehabilitation services. It is designed for individuals who require a higher level of care than what is typically provided in traditional nursing home settings.

B. Sub-acute care and nursing home care are identical.

Explanation: This statement is incorrect. Sub-acute care and nursing home care serve different purposes. Sub-acute care is typically provided for individuals recovering from acute medical conditions or surgeries, while nursing homes often cater to individuals with chronic illnesses or long-term care needs.

C. Sub-acute care is reimbursed by either Medicaid or private pay.

Explanation: This statement is not entirely accurate. Sub-acute care may be reimbursed by a variety of sources, including Medicare, private insurance, and, in some cases, Medicaid. The reimbursement sources can vary based on the specific circumstances and the services provided.

D. Professional nursing staff levels are the same as those in traditional nursing home settings.

Explanation: This statement is generally incorrect. Sub-acute care settings often have a higher ratio of skilled healthcare professionals, including nurses and therapists, compared to traditional nursing homes. This higher level of staffing is necessary to meet the more intensive medical and rehabilitation needs of sub-acute care patients.

A. Tell her to use an assistive device until her balance improves. B. Provide information on group exercises for balance training. C. Instruct her to enroll in a general exercise program for 8 weeks. D. Help her to learn how to exercise the core group of muscles

Correct Answer is B

Explanation

A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.

B. Providing information on group exercises for balance training is a suitable intervention.

Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.

Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.

C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.

D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is being discharged from the hospital to a sub-acute unit. The client says to a nurse, "I am not sure I understand the difference between a sub-acute unit and a nursing home. Can you help me understand?" The nurse considers which of the following in formulating a response:

Correct Answer is A

Explanation

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

Correct Answer is B

Explanation

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