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 D

Explanation

MRSA is spread through direct contact with infected persons or infectious droplets.
A. Keeping a safe distance is important but 3 feet away is not enough precaution.
B. MRSA is not airborne and hence not prevented through wearing of masks
C. The isolation gowns should be disposed in designated areas to prevent the spread of the infection.

A. "The client should be referred to pain management." B. "The client should be referred to hospice services." C. "The client should be referred to a wound, ostomy, and continence nurse." D. "The client should be referred to a dietitian."

Correct Answer is D

Explanation

D. Diet plays a crucial role in managing ulcerative colitis symptoms. Certain foods may trigger flare-ups, while others may be better tolerated. A dietitian can provide personalized dietary advice to help manage symptoms, ensure adequate nutrition, and optimize overall health.
A. Ulcerative colitis is a chronic inflammatory bowel disease that primarily affects the colon and rectum. While pain management is crucial, it is not a priority at this point.
B. Hospice services are generally provided to individuals who have a terminal illness and are nearing the end of life. While ulcerative colitis can be a serious condition, it is not typically considered a terminal illness in itself.
C. A wound, ostomy, and continence nurse (WOCN) specializes in the care of patients with ostomies (such as those resulting from surgery for ulcerative colitis), wounds, and continence issues. The client does not require the services at this point as the decision for the surgery has not been made.

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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

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Explanation

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