A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

1+ pedal edema

Bruises on the lower extremities

Impaired vision

Coarse rhonchi auscultated over the trachea

Answer and Explanation

The Correct Answer is C

A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.

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Correct Answer is A

Explanation

A. Diphenhydramine. Urticaria (hives) is a common allergic reaction often caused by medications like antibiotics. Diphenhydramine, an antihistamine, is used to treat allergic reactions by blocking histamine receptors, reducing itching, swelling, and rash.
B. Hydralazine. This is an antihypertensive medication used to treat high blood pressure, not allergic reactions. It has no effect on histamine or allergic symptoms.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It does not treat allergic reactions like urticaria unless the cause is opioid-induced (which is not indicated here).
D. Protamine. Protamine is used to reverse the effects of heparin. It has no role in treating allergic reactions to antibiotics.

A. Action B. Contemplation C. Maintenance D. Preparation

Correct Answer is A

Explanation

A. Action. The action stage involves actively modifying behaviors, practices, or environments. Since the group is already in the process of reducing pesticide use, they are implementing change, which is characteristic of this stage.
B. Contemplation. In the contemplation stage, individuals or groups are aware a problem exists and are thinking about making a change but have not yet taken action. This does not apply here, as the group has already begun changing their practices.
C. Maintenance. The maintenance stage occurs after a behavior has been successfully adopted and sustained for a period of time. The goal in this stage is to prevent relapse and continue positive behavior, which the group has not yet reached.
D. Preparation. The preparation stage includes planning and small initial steps toward change but not full implementation. Since the group is already working on reducing pesticide use, they have moved beyond this stage.

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A nurse is assessing a client to determine their fall risk. Which of the following findings should alert the nurse that the client is at risk for falls?

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