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 B
Explanation
The correct answer is choice B: Children need time to actively explore their environment. Choice A rationale:
Playpens do provide a sense of security for the child, but confining the child solely to the playpen might hinder their developmental needs. While it is essential to have a safe space for a toddler, children also require opportunities to explore and engage with their environment actively.
Choice B rationale:
The practical nurse (PN) should use this rationale when responding to the parent. Children, especially toddlers, learn and develop crucial skills through active exploration of their environment. Being confined to a playpen for extended periods may limit their opportunities for learning, hinder their physical development, and restrict social interaction, which are essential aspects of their growth.
Choice C rationale:
While playpens can provide a safe environment for a toddler when used appropriately and under supervision, keeping the child confined for the sole purpose of preventing dirtiness is not recommended. Overusing playpens can hinder a child's natural curiosity and desire to explore, potentially affecting their overall development.
Choice D rationale:
While over-concern about appearance can be harmful in some contexts, it is not directly related to the child being kept in a playpen to avoid getting dirty. The primary concern here is about providing the child with adequate opportunities for exploration, growth, and development, rather than focusing solely on appearance.
Correct Answer is C
Explanation
The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.
Choice A rationale:
Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the
use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.
Choice B rationale:
Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.
Choice C rationale:
Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.
Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.
Choice D rationale:
Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.
Neurovascular assessments are more critical for the early detection of complications.
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