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
Ignoring the comment and documenting “No Known Allergies” (NKA) is incorrect because it disregards the client’s report of an allergy. This action could lead to potential harm if the client is indeed allergic to codeine.
Choice B rationale
Asking the client why they think it is an allergy is not the best response. It may come across as dismissive and does not provide the nurse with specific information about the client’s allergic reaction.
Choice C rationale
Telling the client not to worry and that they will be okay if they take codeine with food is incorrect. This response is dismissive of the client’s concern and does not address the potential for an allergic reaction.
Choice D rationale
Asking the client what symptoms they experience with codeine is the best response. It allows the nurse to gather specific information about the client’s allergic reaction, which is crucial for safe medication administration.
Correct Answer is B
Explanation
Choice A rationale
Asking the client to demonstrate a skill is part of the evaluation step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s ability to perform a skill.
Choice B rationale
Showing the client how to use the incentive spirometer is an appropriate action for the implementation step. This step involves providing education and demonstrating skills to the client.
Choice C rationale
Developing a short-term goal for the client is part of the planning step, not the implementation step. The implementation step involves carrying out the teaching plan, not setting goals.
Choice D rationale
Assessing the client’s pain level is part of the assessment step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s condition.
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