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. This response provides the family member with accurate information about the limited effectiveness of drugs in improving appetite and weight gain, along with the potential for serious side effects. It promotes informed decision-making.
B. Stating that there are no drugs that impact appetite or weight gain is not entirely accurate. Some drugs may have an impact, but the effectiveness varies, and they often come with potential side effects.
C. Blanket's statements that these drugs are not permitted in long-term care facilities are not accurate. The use of medications should be based on individual assessment and treatment plans.
D. Saying "Yes, there are some very effective drugs out there. Your mother should be on one of them" is not an appropriate response. It oversimplifies the situation and may not reflect the individualized approach needed in assessing and addressing nutritional concerns.
Correct Answer is ["B","C","D","E"]
Explanation
A. Two servings of deep-colored fruit.
While fruits are recommended, the "deep-colored" specification is not a specific focus in the MyPlate for Older Adults.
B. Six or more servings of fortified, enriched, or whole grain foods.
Correct. Whole grains are an important source of fiber, vitamins, and minerals.
C. Three or more servings of low-fat or nonfat dairy products.
Correct. Dairy products provide calcium and vitamin D, important for bone health.
D. Three 8-ounce glasses of water.
Correct. Staying hydrated is crucial for overall health, especially for older adults.
E. Four or more servings of high-quality protein.
Correct. Protein is essential for muscle maintenance and repair. Sources of high-quality protein include lean meats, poultry, fish, eggs, dairy, and plant-based protein sources.
F. One or two servings of brightly colored vegetables.
While vegetables are recommended, the "brightly colored" specification is not a specific focus in the MyPlate for Older Adults.
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