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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 C

Explanation

A. Stroking the lower abdomen. This technique is not a recognized method for stimulating urination.
B. Performing Kegel exercises prior to urination. Kegel exercises strengthen pelvic muscles but do not directly promote urination.
C. Pouring warm water over the perineum. Warm water can stimulate sensory nerves and promote relaxation of the urethral sphincter, helping to initiate urination.
D. Leaning backward when sitting and attempting to urinate. The proper posture for urination is sitting upright or leaning slightly forward, not backward.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for developing deep vein thrombosis (DVT) due to their immobility.

Rationale:

Swelling and tenderness in the calf are key signs of DVT, which is a common complication of immobility after a stroke.
Immobility leads to venous stasis, increasing the risk of clot formation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who is postoperative and is having difficulty urinating after the removal of an indwelling urinary catheter. Which of the following techniques should the nurse teach the client to use to promote urination?

Correct Answer is C

Explanation

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

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is using the faces, legs, activity, cry, consolability (FLACC) scale to assess the need for PRN pain medication for a client who has cognitive impairment. Which of the following findings should the nurse identify as an indication the client is experiencing pain?

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A nurse is caring for an adolescent client who is preparing for their first pelvic examination. Which of the following techniques should the nurse use to explain the procedure?

A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document?

A nurse is teaching a group of nurses about client confidentiality. Which of the following statements made by a nurse indicates an understanding of the teaching?

A nurse is assessing a client who has posttraumatic stress disorder following the occurrence of a natural disaster. Which of the following questions should the nurse ask to identify the client's support systems?

A nurse is caring for a client who speaks a different language and is having difficulty understanding them. Which of the following actions should the nurse take?