The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?
Ankle ulcer that is healing slowly.
History of alcohol abuse and cigarete smoking.
Recent weight gain of twenty pounds.
Newly prescribed antihypertensive medication.
The Correct Answer is D
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
These are the correct supplies for the PN to gather because they are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site and secure it with paper tape after removing the saline lock.
C. A three mL syringe is not needed to remove a saline lock and may cause confusion or harm if used incorrectly.
E. Sterile gloves are not needed to remove a saline lock and may be wasteful or unnecessary.
Correct Answer is C
Explanation
The correct answer is Choice C. Soft blanket.
Choice A rationale:
A heating pad should not be applied to the client's legs with a mottled appearance. A mottled appearance indicates poor circulation, and applying heat could potentially worsen the situation by dilating blood vessels and further reducing blood flow to the extremities.
Choice B rationale:
The body lotion is not appropriate in this situation. While it may help moisturize the skin, it will not address the underlying circulation issues causing the mottled appearance. Moreover, applying lotions to areas with compromised circulation can be harmful.
Choice C rationale:
The correct choice. A soft blanket can be applied to the client's legs with a mottled appearance to provide warmth and comfort. It is essential to keep the client comfortable during palliative care, and a soft blanket can help maintain a suitable temperature without causing harm.
Choice D rationale:
Moist clothes are not indicated in this situation. They may potentially worsen the mottled appearance by adding moisture to the skin, and it won't address the circulation issues causing the discoloration.
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