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) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.
B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.
C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.
D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.
Correct Answer is A
Explanation
A) "You will have control of administering your own pain medication":
This statement accurately describes the function of a PCA (Patient-Controlled Analgesia) device, where the client has control over administering their own pain medication within preset limits. Empowering the client to manage their pain helps promote autonomy and individualized pain management.
B) "The pain medication is delivered into your muscle":
This statement is incorrect because PCA devices typically deliver medication intravenously, not into the muscle. It's important for the client to understand the route of administration to use the device effectively and safely.
C) "Your partner can push the PCA button for you if you are asleep":
Allowing someone else to activate the PCA button for the client can lead to overmedication and is not recommended. PCA devices are designed for the client to self-administer medication based on their own pain experience and need.
D) "A large dose of pain medication is given with each injection":
This statement is inaccurate because PCA devices are programmed to deliver a controlled dose of medication with each activation, usually within safe limits set by the healthcare provider. The doses are typically set to avoid overdosing while providing effective pain relief.
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