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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Continue to talk to the client as if they are awake: Even though the client is unresponsive, hearing can be the last sense to diminish as death approaches. Speaking to the client in a calm and reassuring manner can provide comfort and a sense of presence, even if the client cannot respond verbally.

B. Limit the client's visitors to one at a time: While it's important to manage visitors to prevent overwhelming the client, limiting them to one at a time may not be necessary if the client's condition allows for multiple visitors and the client's wishes or cultural preferences support it.

C. Avoid touching the client: Touch can be a powerful form of communication and comfort, even for an unresponsive client. Gentle touch can convey warmth and support to both the client and their family members.

D. Whisper when talking in the client's room: Whispering may create a sense of unease or anxiety for the client or their family members. Speaking in a calm and soothing voice at a normal volume is more appropriate and can help create a peaceful environment for the client's end-of-life care.

A. Chocolate milk B. Diet cola C. Brewed iced tea D. Lemon-lime soda

Correct Answer is D

Explanation

A. Chocolate milk:
Chocolate contains caffeine, which can contribute to sleep disturbances. It is not a recommended beverage for someone looking to decrease caffeine intake.

B. Diet cola:
Cola contains caffeine, even in diet versions, which can contribute to sleep disturbances. Therefore, it is not suitable for decreasing caffeine intake.

C. Brewed iced tea:
Brewed iced tea contains caffeine, which can interfere with sleep. It is not a suitable option for someone trying to reduce caffeine consumption.

D. Lemon-lime soda:
Lemon-lime sodas typically do not contain caffeine, making them a better choice for someone looking to reduce their caffeine intake and improve sleep.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?

Correct Answer is D

Explanation

A nurse is caring for a client who reports stress related to homelessness. The nurse should identify that the client is experiencing which of the following types of stressors?

What would be the primary focus of interventions for a client who sleepwalks?

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?

A nurse instructs a class of older adult women about Kegel exercises. In which of the following urinary conditions would Kegel exercises be effective?

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

A nurse is teaching a class about the use of pain medications for clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic? (Select All that Apply)

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take?