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 C

Explanation

A. Keeps room temperature at 72°F.

Explanation: Maintaining a room temperature of 72°F is generally considered comfortable and is not likely to contribute to hyperthermia, especially when compared to higher temperatures. However, it's essential to consider individual preferences and comfort levels.

B. Has a history of osteoarthritis.

Explanation: Osteoarthritis itself is not directly associated with an increased risk of hyperthermia. However, limitations in mobility or difficulties with self-care due to osteoarthritis might indirectly impact the ability to stay cool and hydrated, so comprehensive care should consider the overall health status of the individual.

C. Takes furosemide 40 mg daily.

Explanation: Furosemide is a diuretic that increases urine production, leading to fluid loss. Dehydration or electrolyte imbalances resulting from diuretic use can contribute to an increased risk of hyperthermia, especially in hot weather. It's important for healthcare providers to monitor and manage medications, considering their potential effects on fluid balance and thermoregulation.

D. Bathes daily with a hot shower.

Explanation: While taking hot showers may contribute to temporary elevation of body temperature, bathing alone may not be a significant contributor to hyperthermia. However, if an older adult has difficulty tolerating heat or maintaining hydration, it's essential to consider the cumulative impact of various factors.

A. Use cool or tepid water. B. Avoid alcohol. C. Minimize exertion D. Wear cool clothing such as silk on polyester E. Drink plenty of fluids.

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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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

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

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