A home health nurse is educating a student nurse about fall risk factors in the home. Which client would the student identify as having the highest risk of falling, demonstrating understanding of the teaching?
A 68-year-old client with stage 2 thyroid cancer who takes levothyroxine daily
An 82-year-old client with diabetes mellitus who takes metformin daily
A 78-year-old client with decompensated heart failure who is dyspneic on exertion
A 74-year-old client with hypertension taking lisinopril
The Correct Answer is C
A. Although thyroid cancer and medication use can affect health, they are not the most immediate factors influencing fall risk compared to heart failure symptoms.
B. Diabetes mellitus and metformin use are not directly associated with increased fall risk as much as heart failure and its symptoms.
C. Decompensated heart failure and dyspnea on exertion significantly increase fall risk due to decreased physical stability and balance issues.
D. While hypertension and lisinopril can contribute to fall risk, they are less directly impactful than the symptoms of decompensated heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While refusal to eat can be a normal part of the dying process, it is important to address the family’s concerns and provide comfort, rather than dismissing their worries.
B. Refusing to eat at the end of life can often lead to a sense of peacefulness and is a common part of the dying process. It’s important to reassure the family and focus on comfort.
C. Planning a schedule for high-calorie liquids may not be appropriate or aligned with the client’s comfort and goals of care at the end of life.
D. A feeding tube is generally not indicated in hospice care as it may not contribute to the comfort and quality of life for the client at this stage.
Correct Answer is B
Explanation
A. While willingness to participate is important, it is not the primary concern compared to the client’s ability to understand and learn the material.
B. Assessing the client’s readiness and ability to learn is crucial for tailoring the education effectively and ensuring that the client can understand and apply the information.
C. Previous knowledge and interest are relevant but secondary to ensuring that the client is ready and able to learn the material.
D. Understanding the client's language proficiency is important, but it is part of assessing the ability to learn rather than a standalone priority.
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