A nurse is assisting with the care of a client.

Exhibits
A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Uses a cane to ambulate.

Macular degeneration.

Grab bar in the bathroom

Electrical cord on floor over walkway.

Throw rugs over tile floors

Answer and Explanation

Correct Answer : B,D,E

Choice A reason : Using a cane to ambulate is generally a measure to improve stability and reduce the risk of falling for individuals who may have balance or mobility issues. It is not inherently a risk factor for falls; rather, it is a compensatory strategy to mitigate the risk of falls1.
Choice B reason : Macular degeneration can significantly impact visual acuity and contrast sensitivity, leading to difficulties in navigation and increasing the risk of tripping or misjudging distances. Poor vision is a well-documented risk factor for falls, especially in unfamiliar or complex environments.
Choice C reason : A grab bar in the bathroom is a safety device installed to provide stability and support for individuals while they are using the bathroom facilities. It is a preventive measure against falls and does not increase the risk of falling.
Choice D reason : An electrical cord on the floor over a walkway is a tripping hazard. It is a common home hazard that can cause falls, especially in the elderly or those with mobility and visual impairments78.
Choice E reason : Unsecured throw rugs over tile floors are a recognized fall hazard. They can easily slip underfoot or cause tripping if the edges are not secured, which is particularly dangerous in areas like the kitchen where spills can make the floor even more slippery.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason : Prolonged stress can lead to impaired immune function. When a person is stressed, the body's stress response can suppress the immune system, making it less effective at fighting off infections. This is because stress hormones like cortisol can inhibit the production and function of white blood cells, such as lymphocytes, which are crucial for the immune response. Additionally, chronic stress can lead to inflammation and reduce the body's ability to respond to immunological challenges, increasing the risk of illness and infection.

Choice B reason : Decreased blood pressure is not typically a manifestation of prolonged stress. In fact, stress can lead to increased blood pressure due to the release of stress hormones that cause vasoconstriction and an increase in heart rate. Over time, this can contribute to hypertension and cardiovascular problems.

Choice C reason : Hypoglycemia, or low blood sugar, is not a direct manifestation of prolonged stress. However, stress can affect blood sugar levels. For individuals with diabetes, stress can make it harder to control blood sugar as stress hormones can cause blood sugar levels to rise. In non-diabetic individuals, stress typically does not cause hypoglycemia.

Choice D reason : Anemia, a condition characterized by a lack of healthy red blood cells, is not a direct result of prolonged stress. Anemia can be caused by a variety of factors, including nutritional deficiencies, chronic diseases, or genetic conditions, but it is not commonly linked to stress.

A. Dry mouth B. Hypertension C. Memory loss D. Medications

Correct Answer is A

Explanation

Choice A reason : Dry mouth, also known as xerostomia, is a common side effect of diphenhydramine, an antihistamine used to treat insomnia among other conditions. It occurs because diphenhydramine has anticholinergic properties, which means it inhibits the action of the neurotransmitter acetylcholine. This inhibition can reduce saliva production, leading to a feeling of dryness in the mouth.

Choice B reason : Hypertension, or high blood pressure, is not a typical side effect of diphenhydramine. While some medications, particularly decongestants, can raise blood pressure, diphenhydramine does not usually have this effect. However, individuals with pre-existing heart conditions should consult a healthcare provider before using it.

Choice C reason : Memory loss is not commonly listed as a side effect of diphenhydramine. However, because it can cause drowsiness and has sedative effects, it may lead to temporary forgetfulness or confusion, especially in older adults or when taken in higher doses.

Choice D reason : 'Medications' is not an adverse reaction but rather a general term for drugs used to diagnose, treat, or prevent illness. In the context of diphenhydramine, it would be more appropriate to discuss specific side effects or adverse reactions related to its use.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the care of a client. Exhibits A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress?

Correct Answer is A

Explanation

A nurse is assisting with teaching a client about over-the-counter medications used to treat insomnia. The nurse should include that which of the following is an adverse reaction of diphenhydramine?

Correct Answer is A

Explanation

A nurse is assisting with teaching a class about motor skills that develop in the first year of life. The nurse should include that which of the following motor skills develops first?

A nurse is assisting with teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor?

A nurse is caring for a client who is at the end of life and is experiencing dyspnea. Which of the following actions should the nurse take?

A nurse is caring for a client who has a new diagnosis of diabetes mellitus. The client states, "I will never be able to follow the prescribed diet." Which of the following statements should the nurse make?

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take?

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has diabetic neuropathy about foot care. Which of the following instructions should the nurse include?

A nurse is caring for an adolescent client who reports they are beginning to rebel against their caregivers and spend more time with their friends. The nurse should identify that the client is experiencing which of the following stages of Erikson's theory of psychosocial development?

A nurse is assisting with the care of a client.

Exhibits
A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.