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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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. A 21-year-old client who had a normal Pap test one year ago. The American Cancer Society (ACS) and the U.S. Preventive Services Task Force (USPSTF) recommend that cervical cancer screening (Pap test) begin at age 21, regardless of sexual history. Screening should be done every 3 years for individuals aged 21-29, assuming results are normal. Since this client had a Pap test one year ago, they do not need immediate screening but should follow the standard 3-year interval.
B. A 32-year-old client who had a total vaginal hysterectomy last year. A total hysterectomy (removal of the uterus and cervix) for non-cancerous reasons generally means that Pap tests are no longer necessary. However, if the hysterectomy was due to cervical cancer, continued screening might be needed.
C. A 47-year-old client who had a negative combined Pap and HPV test 5 years ago. For clients 30-65 years old, Pap tests can be done every 3 years OR combined Pap and HPV (co-testing) every 5 years. Since this client had a negative co-test 5 years ago, they are due for screening now, but they would not have been referred earlier.
D. A 15-year-old client who recently completed the vaccine series for human papillomavirus (HPV). The HPV vaccine does not replace the need for Pap tests but helps reduce the risk of cervical cancer. Routine Pap testing does NOT begin before age 21, so this client does not yet need screening.

A. Speech therapist B. Occupational therapist C. Physical therapist D. Recreational therapist

Correct Answer is B

Explanation

A. "Speech therapist" –
A speech therapist helps clients with swallowing difficulties (dysphagia) and communication impairments but does not focus on activities of daily living (ADLs) like dressing and toileting.
B. "Occupational therapist" –
An occupational therapist assists clients in regaining independence with ADLs, such as dressing, toileting, and bathing, by teaching adaptive techniques and recommending assistive devices.
C. "Physical therapist" –
A physical therapist focuses on improving mobility, strength, and balance but does not specifically address dressing and toileting tasks.
D. "Recreational therapist" –
A recreational therapist works on improving the client’s quality of life through leisure activities and social engagement, not basic self-care tasks.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the records of several clients to determine cervical cancer screening recommendations. Which of the following clients should the nurse refer for a Papanicolaou (Pap) test?

Correct Answer is A

Explanation

A nurse is caring for a client who has had a stroke and is having difficulty with dressing and toileting. With which of the following therapists should the nurse schedule a referral for the client?

Correct Answer is B

Explanation

A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?

A nurse is teaching a client about prevention of injury when lifting. Which of the following instructions should the nurse include in the teaching?

A nurse is planning an in-service to teach families about self-care resources for caregivers. Which of the following programs should the nurse plan to include?

A nurse is inspecting equipment safety in a client's home. The nurse should identify that which of the following findings requires an intervention?

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 group of clients. Which of the following actions by the nurse demonstrates client advocacy?

A nurse has initiated an incident report for a missed dose of medication on a client that caused no harm to the client. Which of the following responses by the nurse manager indicates the use of just culture?