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","B","C","D","F"]

Explanation

A. Right to visitation from others except legal advisors, who must obtain permission from the nursing facility before visiting the older adult

Explanation: The right to receive visitors is generally protected, with some reasonable restrictions, to ensure the safety and well-being of residents.

B. Right to be free from restraints

Explanation: Residents have the right to be free from unnecessary physical or chemical restraints, as outlined in their Bill of Rights. Restraints should only be used when necessary for the safety of the resident or others, and their use should be minimized.

C. Right to have a say in their care and treatment

Explanation: Residents have the right to actively participate in decisions about their care and treatment. This includes being informed about their options and having the opportunity to express their preferences.

D. Right to voice grievances

Explanation: Residents have the right to voice complaints or grievances without fear of retaliation. The nursing home must have a system in place to address and resolve residents' concerns.

E. "Right to information about their health but not about their medications" is not accurate. Residents have the right to be informed about all aspects of their health, including information about medications prescribed to them. Information about medications is an important component of informed consent and shared decision-making.

F. Right to be free from abuse

Explanation: Residents have the right to be free from any form of abuse, whether it is physical, verbal, psychological, or any other form. Nursing homes must take measures to prevent and address any instances of abuse.

A. Comprehensive assessment B. Assessing for atypical presentation of Illness C. Complete blood count D. Differentiating delirium, dementia, and depression

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

Explanation

A. Comprehensive assessment

Explanation: A comprehensive assessment involves a thorough evaluation of various cognitive functions, including memory, attention, language, problem-solving, and executive functions. This allows for a comprehensive understanding of an individual's cognitive abilities.

B. Assessing for atypical presentation of illness

Explanation: Assessing for atypical presentation of illness is relevant in a cognitive assessment because some medical conditions or illnesses can manifest with cognitive symptoms. Recognizing atypical presentations helps in identifying potential underlying causes of cognitive changes.

C. Complete blood count

Explanation: While laboratory tests like a complete blood count (CBC) may be useful in identifying certain medical conditions that could affect cognition, it is not a direct component of a cognitive assessment. Cognitive assessments typically involve clinical interviews, neuropsychological testing, and observation of cognitive functions. Blood tests and other diagnostic tools may be used to complement the cognitive assessment but are not considered components of it.

D. Differentiating delirium, dementia, and depression

Explanation: Distinguishing between delirium, dementia, and depression is crucial in a cognitive assessment. Each condition has distinct characteristics, and accurate differentiation is necessary for appropriate intervention and management.

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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

The Bill of Rights for long-term residents was created to protect the rights of the residents in nursing homes. Which of the following examples protect these rights? (Select all that apply.)

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

Explanation

Components to a cognitive assessment include which of the following? (Select all that apply.)

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

Explanation

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In assessing an older adult, you question his cognitive skills when you notice that

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To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

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?

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