A home health nurse is performing an in-home fall assessment for a client. Which of the following findings should the nurse identify as a potential hazard for the client?
Electrical cords secured to the baseboards
A computer chair with wheels that lock
A standard toilet seat in the bathroom
Carpeted floors in the kitchen
The Correct Answer is C
Choice A reason: Electrical cords secured to the baseboards are safe because they reduce tripping hazards. Loose cords across walkways would be dangerous, but secured cords are appropriate.
Choice B reason: A computer chair with wheels that lock is safe. Locking wheels prevent the chair from rolling unexpectedly, reducing fall risk.
Choice C reason: A standard toilet seat can be a hazard for clients at risk of falls because it is low and requires significant effort to sit and stand. Raised toilet seats or grab bars are recommended to reduce strain and prevent falls. This is the correct hazard identified.
Choice D reason: Carpeted floors in the kitchen are not typically a fall hazard. In fact, carpeting can reduce slipping compared to smooth surfaces. The greater concern in kitchens is wet or greasy floors, not carpeting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: An oral temperature of 35.4° C (95.7° F) indicates hypothermia, which is a serious complication of eating disorders such as anorexia nervosa. Hypothermia suggests severe malnutrition and impaired thermoregulation, requiring immediate medical evaluation. This makes option A the correct answer.
Choice B reason: A resting heart rate of 60/min is within the normal range for adults. While bradycardia can occur in clients with eating disorders, a rate of 60/min is not alarming and does not require urgent referral. This option is incorrect.
Choice C reason: A urine output of 320 mL in 8 hours is slightly below the expected minimum of 30 mL per hour (240 mL in 8 hours). While this is reduced, it is not critically low and does not immediately necessitate referral unless it persists or worsens. This option is incorrect.
Choice D reason: A blood pressure of 100/68 mm Hg is within the normal range and does not indicate an acute complication. This option is incorrect because it does not represent a dangerous finding.
Correct Answer is A
Explanation
Choice A reason: A fetal heart rate of 152/min at 28 weeks gestation is within the normal range of 110–160 beats per minute. This is an expected finding and indicates adequate fetal oxygenation and well-being.
Choice B reason: Absence of fetal movement for 8 hours is concerning and not expected. At 28 weeks, fetal movement should be felt regularly. Lack of movement may indicate fetal distress or compromise and requires immediate evaluation.
Choice C reason: Cramping and pelvic pressure at 28 weeks may indicate preterm labor. These are not expected findings and should be promptly reported and assessed to prevent complications.
Choice D reason: A patellar reflex of 4+ indicates hyperreflexia, which is abnormal and may suggest preeclampsia or other neurologic complications. Normal reflexes are 2+. Therefore, this is not an expected finding.
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