A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.

A patient who experiences postural hypotension.

A patient who is experiencing nausea from chemotherapy.

A patient who has already fallen twice.

A patient who is older than 50 years old.

A patient who is transferred to long-term care.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale

A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.

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Correct Answer is A

Explanation

Choice A rationale
Facial expressions are indeed an example of non-verbal communication. Non-verbal communication includes body language, facial expressions, gestures, and eye contact. These cues can provide significant insights into a client’s feelings and attitudes.
Choice B rationale
Verbal communication is not always an accurate reflection of what the client really feels. Clients may sometimes say what they think the nurse wants to hear or may not fully express their true feelings verbally.
Choice C rationale
Nonverbal communication often reflects what the client is truly feeling more accurately than verbal communication. For example, a client may say they are not in pain, but their body language, such as grimacing or guarding a body part, may indicate otherwise.
Choice D rational
Body posture is an example of non-verbal communication, not verbal communication. Verbal communication involves spoken or written words, while non-verbal communication includes body language, facial expressions, and other physical cues.

A. On initial evaluation by the home health nurse. B. Reassessing a client for pain after giving pain medication. C. Checking skin assessment on a patient with a medical device in place. D. Preparing the client for discharge.

Correct Answer is B

Explanation

Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.

Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a client’s verbal and nonverbal behavior. Which principles influence communication?

Correct Answer is A

Explanation

In what patient situations would a partial ongoing assessment be best performed?

Correct Answer is B

Explanation

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

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A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls.
Which patients would the nurse consider to be in this category? Select all that apply.