A nurse is conducting a fall risk assessment for a patient.
Which of the following factors would increase the patient’s risk of falling?
The presence of a grab bar in the bathroom.
An electrical cord lying across a walkway.
The patient has macular degeneration.
There are throw rugs in the kitchen.
The patient uses a cane to ambulate.
Correct Answer : B,C,D,E
Choice A rationale
The presence of a grab bar in the bathroom is actually a safety measure that can help prevent falls. It provides support for the patient when they are getting up or moving around, reducing the risk of a fall.
Choice B rationale
An electrical cord lying across a walkway is a tripping hazard and would increase the patient’s risk of falling. It is important to keep walkways clear of clutter and potential obstacles to prevent falls.
Choice C rationale
Macular degeneration can affect the patient’s vision, making it difficult for them to see obstacles or changes in the walking surface. This can increase their risk of falling.
Choice D rationale
Throw rugs in the kitchen can easily slip or bunch up, creating a tripping hazard. They should be secured with non-slip backing or removed to reduce the risk of falls.
Choice E rationale
While a cane can provide support and improve balance, it also indicates that the patient has mobility issues, which increases their risk of falling. It is important that the patient uses the cane correctly and that it is the right height for them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice B rationale
Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse
should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.
Choice C rationale
Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice D rationale
Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Correct Answer is B
Explanation
Choice A rationale
Constipation is not typically resolved by diluting enteral feeding formula.
Choice B rationale
Diarrhea can be a common side effect of enteral feeding, and diluting the formula can help manage this.
Choice C rationale
While electrolyte imbalance can occur with enteral feeding, diluting the formula is not typically done to resolve this issue.
Choice D rationale
Delayed gastric emptying is not typically resolved by diluting enteral feeding formula.
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