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 B

Explanation

A. "My home has running water and electricity." This statement suggests adequate access to basic utilities, which supports hygiene and reduces risk for illness. It does not indicate a health risk.
B. "I eat vegetables directly from the field where I work." This poses a significant health risk due to potential pesticide exposure and contamination with harmful chemicals or microbes. Produce should be properly washed before consumption to reduce the risk of illness or poisoning.
C. "I wear a hat and long sleeves while I am working." This is a protective behavior, helping to reduce sun exposure, skin damage, and pesticide contact, and is not a health risk.
D. "I am currently sharing my home with two roommates." While crowded living conditions can pose some risk, this alone does not indicate a major health concern, especially if basic sanitation and ventilation are adequate.

A. Changes from prone to sitting B. Rolls from back to abdomen C. Sits steadily unsupported D. Rolls from back to side

Correct Answer is D,B,C,A

Explanation

D. Rolls from back to side usually occurs around 4 months of age as the infant begins developing trunk strength.

B. Rolls from back to abdomen typically follows at around 5 to 6 months, indicating improved coordination and strength.

C. Sits steadily unsupported usually develops around 8 months, showing advanced balance and postural control.

A. Changes from prone to sitting is a more complex skill that typically appears around 10 months, requiring significant core strength and motor planning.

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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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Naxlex Comprehensive Predictor Exams

A nurse working in a health department is conducting a health screening for a group of farmworkers. Which of the following client statements indicates a possible health risk?

Correct Answer is B

Explanation

A nurse is teaching a group of parents about expected development of gross motor skills during infancy. The nurse should teach that the following developmental tasks are expected to occur in what order? (Move the steps into the box, placing them in the order of performance. Use all the steps.)

Correct Answer is D,B,C,A

Explanation

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