The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?

An adult patient who has left arm weakness secondary to a childhood injury.

An elderly patient who requires eye glasses for reading small print on labels and newspapers.

A patient who is confused and experiencing nausea due to a head injury.

A patient who uses the grab bars located in the hospital bathroom.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

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Correct Answer is C

Explanation

Choice A rationale:

Providing non-slip footwear to patients during their stay is a good preventive measure, but it only addresses the risk of falls related to slippery floors. It does not address the overall fall risk, especially for elderly patients who may need constant supervision and assistance.

Choice B rationale:

Keeping the bed in a high position for ease of care might seem practical, but it increases the risk of falls when the patient attempts to get out of bed. Lowering the bed reduces the risk of injury if a fall occurs and is a more appropriate intervention.

Choice C rationale:

Instituting a policy requiring a sitter for all patients above the age of 60 is the best option among the choices provided. Elderly patients are at a higher risk of falls due to various factors such as weakened muscles, balance issues, and medication side effects. Having a dedicated sitter ensures constant supervision, timely assistance, and prompt intervention if the patient attempts to get out of bed, significantly reducing the risk of falls.

Choice D rationale:

Avoiding the use of a night light in the room to promote sleep is not a recommended intervention. While promoting sleep is essential for overall patient well-being, patient safety should always be the priority. Providing adequate lighting, especially at night, reduces the risk of falls and other accidents.

A. Extension. B. Abduction. C. Flexion. D. Adduction.

Correct Answer is C

Explanation

Choice A rationale:

Extension refers to the straightening of a joint and is the opposite of flexion. It is not the correct term for the described hand movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It does not describe the specific movement of the patient's hand toward the inner aspect of the forearm.

Choice C rationale:

Flexion is the bending of a joint, decreasing the angle between two body parts. When the nurse moves the patient's hand toward the inner aspect of the forearm, it is a flexion movement of the wrist.

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. It is not the correct term for the described hand movement.

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The nurse is caring for several patients on a medical unit.Which patient does the nurse identify as being most at risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is implementing interventions to reduce the number of falls in the health care facility.What action is best for the nurse to implement?

Correct Answer is C

Explanation

The nurse moves the patient's hand toward the inner aspect of the patient's forearm.This range of motion exercise would be documented as what of the wrist?

Correct Answer is C

Explanation

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The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?