Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care?

Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

Recent serum hemoglobin level of 16 g/dL (160 g/L).

Opioid analgesic received one hour ago.

Expressed feelings of depression.

Stooped posture with a steady gait.

Answer and Explanation

The Correct Answer is B

A.   A serum hemoglobin level of 16 g/dL (160 g/L) is within the normal reference range for adults (14 to 18 g/dL). Hemoglobin levels that are within the normal range generally do not indicate a direct risk for falls. Low hemoglobin (anemia) could potentially increase fall risk due to fatigue or dizziness, but a normal level is not a risk factor for falls.
B.   Opioid analgesics are known to have side effects such as sedation, dizziness, and impaired motor coordination, which can increase the risk of falls. The recent administration of opioids makes this a significant factor in assessing fall risk, as the client may still be experiencing side effects from the medication that could impair their balance or cognitive function.
C.   Depression can contribute to fall risk in several ways, including reduced motivation to engage in activities, decreased physical strength, and impaired attention. However, while important to address, depression alone is not as immediate or direct a risk factor for falls compared to factors like recent medication side effects or actual physical impairments.
D.   Stooped posture may be indicative of issues such as musculoskeletal problems or balance difficulties. However, if the client has a steady gait, it suggests that despite the stooped posture, their current ability to walk is stable. The stooped posture alone might increase fall risk over time, but it is not as directly related to the immediate risk of falls as recent medication effects.

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Correct Answer is A

Explanation

A. Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B. While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C. Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D. While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

A. Notify the hospital ethical committee to assist with client's wishes. B. Have resuscitation equipment readily available. C. Document healthcare provider's refusal to honor client's wishes. D. Facilitate a meeting between the healthcare provider and the spouse.

Correct Answer is A

Explanation

A. The ethics committee can provide guidance on how to navigate the conflict between the healthcare provider’s beliefs and the client's documented wishes. The committee can mediate discussions and help ensure that the client's rights and preferences are respected according to legal and ethical standards.
B. While having resuscitation equipment available might be relevant if there is a sudden need for emergency intervention, it does not directly address the issue of honoring the client’s living will. This action does not resolve the ethical conflict or ensure that the client’s wishes are respected.
C. Documenting the healthcare provider’s refusal is important for legal and medical records but does not resolve the situation or ensure that the client’s wishes are respected. Documentation alone does not address the ethical conflict or take action to honor the client’s living will.
D. Facilitating a meeting between the healthcare provider and the spouse could be beneficial for discussing the client’s wishes and potentially reaching a mutual understanding. However, if the healthcare provider remains unwilling to honor the living will despite such discussions, this action alone may not resolve the conflict.

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Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

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Explanation

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Explanation

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Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care?

Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]