Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for an older adult client newly admitted to the medical unit.

Exhibits

Click to highlight the pieces of information that indicate the client is at risk for falls. To deselect a piece of information, click on that piece of information again.

Nurses' Notes

1000:

An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.

Vital Signs

1000:

Temperature 37° C (98.6° F)

Heart rate 72/min Respiratory rate 20/min

Blood pressure

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Oxygen saturation 97% on room air

admitted following a fall down approximately five steps

client possibly hit their head and was a little disoriented for a minute or two

history of falls and orthostatic hypotension per client's partner

uses a walker

Client ordered new glasses following an eye exam last week but has not received them yet

Lying: 130/90 mm Hg

Sitting: 128/88 mm Hg

Standing: 98/60 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H"]

The key pieces of information that indicate the client is at risk for falls include:

Admitted following a fall down approximately five steps – Indicates a recent fall history.
Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
Client uses a walker – Indicates mobility impairment.
Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.

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 D

Explanation

A. "Intensity of pain levels decrease as people age."
Pain perception does not necessarily decrease with age. Older adults experience pain similarly to younger individuals, but they may express it differently.
B. "The client is less likely to respond to analgesics." Older adults respond to analgesics, but they may be more sensitive to certain medications due to age-related physiological changes. Appropriate dosing and monitoring are essential.
C. "Pain is an expected finding for an older adult." Pain is not a normal part of aging. While some chronic conditions associated with aging can cause pain, it should always be assessed and treated appropriately.
D. "The client may under-report their pain intensity."
Older adults may under-report pain due to factors such as fear of being a burden, belief that pain is a normal part of aging, or concerns about medication side effects. Nurses should use appropriate pain assessment tools to evaluate and address their pain effectively.

A. Rest the client's left arm over their chest. B. Apply an orthotic boot to the client's left foot. C. Place a thick pillow behind the client's head to increase cervical flexion. D. Instruct the client to lean toward the left side when ambulating to avoid falls.

Correct Answer is B

Explanation

A. "Rest the client's left arm over their chest." Keeping the affected arm across the chest can lead to contractures and shoulder adduction deformities. Instead, the arm should be supported in a neutral position with pillows or a sling to prevent complications.
B. "Apply an orthotic boot to the client's left foot." Clients with hemiplegia are at risk for foot drop due to muscle weakness or paralysis. An orthotic boot helps maintain proper foot alignment, prevents contractures, and promotes mobility.
C. "Place a thick pillow behind the client's head to increase cervical flexion." Excessive cervical flexion can lead to poor airway alignment and discomfort. Instead, the client’s head should be in a neutral, midline position with proper support.
D. "Instruct the client to lean toward the left side when ambulating to avoid falls." Leaning toward the affected (weaker) side increases the risk of imbalance and falls. Instead, the client should be encouraged to maintain proper posture and use assistive devices (e.g., cane, walker) for stability.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client who reports pain. Which of the following should the nurse recognize about the client's perception of pain?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who has left-sided hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who was admitted for an exacerbation of their COPD. The client will be discharged with a new prescription for oxygen therapy and will need assistance with activities of daily living. Which of the following referrals should the nurse obtain for the client?

A nurse is caring for a client. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing dropdowndue todropdown

A nurse is caring for a client who had a stroke. Exhibits Complete the following sentence using the lists of options. The client is at risk for developing dropdowndue to theirdropdown

A nurse is caring for a client who has a prescription for parenteral therapy. Which of the following actions should the nurse take when initiating IV therapy?

A nurse is preparing to obtain a health history from a newly admitted client. Which of the following information should the nurse expect to include?

A nurse caring for a client who has a prescription for morphine 5 mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?

A nurse is planning to provide discharge teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?