A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

The client asks for help before ambulating.

The client has a history of urinary incontinence.

The client lives with their caregiver.

The client has bronchitis.

Answer and Explanation

The Correct Answer is B

B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.

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Correct Answer is ["A","B","C","D","E","J"]

Explanation

The client is having typical signs and symptoms of acute coronary syndrome - pain radiating to the left arm, nausea, diaphoresis, shortness of breath and tachycardia

Her diet history - daily bacon and eggs increases her cardiovascular risk

Her cool skin and weak peripheral pulses is an indication of poor perfusion due to impaired myocardial contractility due to myocardial infarction.

A. Avoid getting a flu vaccination. B. Limit fluids to 1.5 L per day. C. Limit alcohol intake to one drink per day. D. Avoid extremely hot or cold temperatures.

Correct Answer is D

Explanation

D. Extreme temperatures, both hot and cold, can trigger sickle cell crises in individuals with sickle cell disease. Cold temperatures can cause vasoconstriction and increase the risk of sickling of red blood cells, while hot temperatures can lead to dehydration. Therefore, clients with sickle cell disease should avoid exposure to extreme temperatures and take precautions to maintain a comfortable environment, especially during hot summer months and cold winter seasons.
A. Clients with sickle cell disease are at increased risk of developing complications from influenza (flu) infections. Therefore, it is highly recommended that clients with sickle cell disease receive an annual flu vaccination to reduce their risk of contracting the flu and its associated complications.
B. Hydration is crucial for individuals with sickle cell disease as it helps prevent dehydration and reduces the risk of sickling of red blood cells, which can trigger a sickle cell crisis.
C. Alcohol can exacerbate dehydration and increase the risk of vaso-occlusive crises in individuals with sickle cell disease.

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A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","J"]

Explanation

A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the include?

Correct Answer is D

Explanation

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

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