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 ["A","B","D"]
Explanation
The correct answer is choicea. Increase daily caloric intake by 300 to 400 calories,b. Consume folic acid supplements daily, andd. Take daily iron and calcium supplements.
Choice A rationale:
Pregnant teenagers need to increase their daily caloric intake by 300 to 400 calories to support the growth and development of the fetus.
Choice B rationale:
Folic acid is crucial for preventing neural tube defects in the developing fetus.Daily supplementation is recommended.
Choice C rationale:
Pregnant teenagers need to increase their protein intake to support fetal growth and maternal health.Maintaining current protein intake is not sufficient.
Choice D rationale:
Iron and calcium are essential for the development of the fetus and the health of the mother.Daily supplementation helps prevent deficiencies.
Choice E rationale:
Limiting weight gain to no more than 15 pounds is not recommended.Healthy weight gain during pregnancy varies but is generally higher than 15 pounds to support fetal development.
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
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