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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Following the order as prescribed without clarification can lead to errors if the order is unclear or incomplete.
Choice B rationale
Administering the medication at a later time without clarification can also lead to errors and may delay necessary treatment.
Choice C rationale
Disregarding the order and seeking approval from another physician is not appropriate. The nurse should seek clarification from the ordering physician.
Choice D rationale
Asking the physician to clarify the dosage and route ensures that the order is accurate and complete, reducing the risk of medication errors.
Correct Answer is C
Explanation
Choice A rationale
Maintaining confidentiality of patient information is crucial, but it falls under the principle of confidentiality, not fidelity.
Choice B rationale
Remaining loyal and faithful to one’s personal beliefs and values is important, but it is not the primary focus of fidelity in nursing practice.
Choice C rationale
Upholding professional obligations and commitments is the essence of fidelity in nursing. It involves being faithful to the promises made to patients and the profession, ensuring trust and integrity in nursing practice.
Choice D rationale
Ensuring equitable distribution of healthcare resources is related to the principle of justice, not fidelity.
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