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 A
Explanation
A. Defecation less than once each day is not necessarily constipation.
Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.
B. Leaking liquid feces should be treated as diarrhea.
Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.
C. Mineral oil is recommended as a laxative for the older adult.
Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.
D. Excessive sleep can be a symptom of constipation.
Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.
Correct Answer is B
Explanation
A. Four-length rails.
Explanation: Four-length rails fully enclose the bed and can be considered a more restrictive measure. They may be used when a restraint order is in place, but for an alert patient without such an order, less restrictive alternatives are preferred.
B. One-length rail.
Explanation: Using one-length rails can be a less restrictive alternative when a patient is at high risk for falling. The use of one side rail allows for some protection against falls without fully restraining the patient. This approach helps maintain the patient's mobility and autonomy while still providing a safety measure.
C. Two full-length rails.
Explanation: While using two full-length rails is less restrictive than four-length rails, it is still more restrictive than using only one side rail. The goal is to balance fall prevention with the patient's autonomy.
D. No side rails.
Explanation: Using no side rails may not provide adequate protection for an alert patient at high risk for falling. While avoiding restraints is essential, implementing at least one side rail is a reasonable compromise to enhance safety without fully restricting the patient's movement.
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