A nurse is assisting with the care of a client.
Exhibits

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.

Macular degeneration

Throw rugs in kitchen

Grab bar in bathroom

Electrical cord on floor over walkway

Uses a cane to ambulate

Answer and Explanation

Correct Answer : A,B,D,E

A. Macular degeneration:

Macular degeneration causes central vision loss, decreasing the client's ability to see obstacles, judge depth perception, or identify hazards in their path. Visual impairment is one of the greatest contributors to fall risk, making this a significant hazard.

B. Throw rugs in kitchen:

Unsecured throw rugs are a well-known environmental fall hazard. They can slide on tile floors or fold, causing the client to trip. These hazards are especially dangerous for older adults or clients using assistive devices.

C. Grab bar in bathroom:

A grab bar is a protective safety device that improves stability during transfers or bathing. Instead of increasing fall risk, grab bars are specifically used to prevent slips and falls. This finding indicates a reduced risk, not an increased one.

D. Electrical cord on floor over walkway:

An electrical cord stretched across a walking path acts as a direct tripping hazard. This is especially dangerous for clients with impaired vision, slower reaction time, impaired gait, or assistive devices.

E. Uses a cane to ambulate:

The need for an assistive device indicates an underlying mobility impairment, decreased balance, or muscle weakness. Even though a cane provides support, the fact that it is required places the client in a higher fall-risk category, particularly if the environment contains additional hazards such as rugs and cords.

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Correct Answer is C

Explanation

A. Consume less than 3000 mg of sodium per day:

While reducing excessive sodium can benefit cardiovascular health and may indirectly reduce physiologic stress, the commonly recommended upper limit for most adults is ≤2300 mg/day (and lower for specific conditions).

B. Increase intake of saturated fats:

Increasing saturated fat intake is associated with negative cardiovascular and metabolic effects and does not reduce stress; a heart-healthy pattern with unsaturated fats (e.g., nuts, fish, olive oil) is preferable.

C. Choose complex carbohydrates each day:

Complex carbohydrates (whole grains, legumes, vegetables) provide steady energy, support stable blood glucose, and promote serotonin synthesis which can help mood regulation and reduce stress; they are preferable to simple sugars.

D. Limit alcohol intake to 3 drinks per day:

Consuming up to three drinks daily is excessive for many and can worsen stress, sleep, and health. Health guidelines recommend limiting alcohol (commonly no more than 1 drink/day for women and up to 2 for men) and less is better for stress reduction.

A. "I will wear earphones during this test." B. "A tuning fork is placed on my head." C. "A small probe is placed inside my ear." D. "Small electrodes are placed on my scalp."

Correct Answer is B

Explanation

A. "I will wear earphones during this test.":

Wearing earphones is not part of the Rinne test (that is used with audiometers for formal audiometry, not the bedside Rinne).

B. "A tuning fork is placed on my head.":

The Rinne test uses a tuning fork placed initially on the mastoid bone (behind the ear) to test bone conduction, then moved next to the ear canal to test air conduction; while the wording “on my head” is imprecise (the Weber test places the fork on the forehead/vertex), this option is the closest to indicating a tuning-fork–based bedside hearing test.

C. "A small probe is placed inside my ear.":

Probes inserted into the ear are used for tympanometry or otoacoustic emissions testing, not the bedside Rinne test.

D. "Small electrodes are placed on my scalp.":

Electrodes on the scalp are used for EEG or auditory brainstem response (ABR) testing-not for Rinne.

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A nurse is assisting with the care of a client.Exhibits 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.

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A nurse is assisting with the care of a client.
Exhibits

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.