A nurse is caring for an older adult client newly admitted to the medical unit.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["440"]
Explanation
Total Intake:
0.9% sodium chloride IV infusion = 600 mL
Cefazolin in D5W IV bolus = 100 mL
Total intake = 600 + 100 = 700 mL
Total Output:
Emesis = 200 mL
Voided urine = 40 mL
Straight catheter urine = 20 mL
Total output = 200 + 40 + 20 = 260 mL
Difference (Intake - Output):
700 mL - 260 mL = 440 mL
Final Answer:
440 mL
Correct Answer is A
Explanation
A. "I will hold my cane on my stronger side." The cane should be held on the stronger (unaffected) side to provide better support and stability while allowing the weaker leg to move more freely.
B. "I should hold my cane 12 inches from my side." The cane should be positioned about 6–10 inches to the side of the foot to ensure proper balance and support.
C. "I will keep my elbow flexed at a 90-degree angle while moving my cane." The elbow should be flexed at about 15–30 degrees, not 90 degrees, to maintain comfort and proper control of the cane.
D. "I should move my weaker leg before moving my cane." The correct sequence is to move the cane first, then move the weaker leg forward, followed by the stronger leg, which provides better stability and reduces fall risk.
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