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 D
Explanation
The correct answer is choice D, Pupils reactive to accommodation. Choice A rationale:
"Peripheral vision intact”. refers to the ability to see objects at the outer edges of one's visual field. It is not relevant to the assessment of pupillary response and does not describe the finding of pupils constricting as they change focus from a far object to a near object.
Choice B rationale:
"Nystagmus present with pupillary focus”. suggests involuntary rapid eye movements accompanied by changes in pupillary response. Nystagmus is not an expected finding during pupillary accommodation, and its presence would indicate a neurological issue rather than a normal response.
Choice C rationale:
"Consensual pupillary constriction present”. refers to both pupils constricting when light is shined into one eye. While this finding is normal, it does not specifically describe the pupils' response during accommodation when focusing from a far object to a near object.
Choice D rationale:
"Pupils reactive to accommodation”. accurately describes the normal physiological response of the pupils constricting as they change focus from a distant object to a nearby object. This response ensures that the appropriate amount of light enters the eyes to maintain clear vision during different distances of focus.
Correct Answer is D
Explanation
The correct answer is choice D. Cleanse the finger with soap and water.
Choice A rationale:
Explaining the occurrence to the client is not the first action the PN should take in this situation. The priority is to address the potential exposure to bloodborne pathogens and ensure the PN's safety.
Choice B rationale:
Observing the appearance of the injection site is important for routine assessment but is not the first action the PN should take after getting stuck with the used needle. Immediate action to clean the wound site is essential to reduce the risk of infection.
Choice C rationale:
While notifying the charge nurse about the incident is important, it should not be the first action taken. The PN's safety should be addressed first by cleansing the finger.
Choice D rationale:
The PN should first cleanse the finger with soap and water immediately after getting stuck with the used needle. This action helps reduce the risk of infection and contamination. After cleansing, the PN can follow the facility's protocol for reporting incidents and seek necessary medical attention if required.
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