A nurse is conducting a fall risk assessment for her clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
An older adult who is confused and has urinary frequency
An older adult with hearing impairment
A client who has a dressing on his foot due to a pressure ulcer
A client who has osteoarthritis and uses a walker
The Correct Answer is A
A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.
B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.
C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.
D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Transport the patient safely and quickly when going to the radiology department: While it's important to transport patients safely and efficiently, this action does not directly address the prevention of disease spread associated with contact precautions. Contact precautions primarily involve preventing direct or indirect contact with the patient's bodily fluids or contaminated surfaces.
B) Use a dedicated blood pressure cuff that stays in the room and is used for that patient only: This is the most appropriate action for preventing the spread of disease on contact precautions. Using dedicated equipment for the patient reduces the risk of cross-contamination between patients. It helps prevent the transmission of pathogens from one patient to another through contaminated equipment.
C) Place the patient in a room with negative airflow: Negative airflow rooms are typically used for patients on airborne precautions to prevent the spread of airborne pathogens. While maintaining appropriate airflow is important for infection control, it is not specific to contact precautions.
D) Wear a gown, gloves, face mask, and goggles for interactions with the patient: This option describes the appropriate personal protective equipment (PPE) to wear when caring for a patient on contact precautions. While it's important to wear PPE, using dedicated equipment for the patient is more directly related to preventing disease spread in this scenario
Correct Answer is B
Explanation
A. Functional incontinence: Functional incontinence occurs when a person has difficulty reaching the toilet due to physical or cognitive impairments, such as mobility issues or dementia. Kegel exercises, which focus on strengthening the pelvic floor muscles, would not directly address the underlying causes of functional incontinence.
B. Stress incontinence: Stress incontinence is characterized by the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, laughing, or exercising. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help support the bladder and reduce the occurrence of stress incontinence.
C. Urinary retention: Urinary retention refers to the inability to empty the bladder completely. While Kegel exercises may help improve bladder control, they are not typically used to address urinary retention, which often requires other interventions such as medications, catheterization, or surgery.
D. Fecal incontinence: Fecal incontinence involves the involuntary leakage of stool. Kegel exercises are not effective for addressing fecal incontinence, as they primarily target the pelvic floor muscles involved in urinary control, not bowel control. Treatment for fecal incontinence may include dietary modifications, medications, pelvic floor rehabilitation, or surgical interventions, depending on the underlying cause.
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