A nurse is reviewing a client's electronic medical record (EMR). Which of the findings should the nurse identify as a risk factor for a potential accident or injury?
History of dementia
Steady gait
History of gastric reflux
Age of 45
The Correct Answer is A
A. History of dementia- Dementia can impair cognitive function and increase the risk of accidents or injuries, such as falls or wandering.
B. Steady gait- A steady gait indicates good balance and is not typically considered a risk factor for accidents or injuries.
C. History of gastric reflux- Gastric reflux may cause discomfort but is not directly related to an increased risk of accidents or injuries.
D. Age of 45- While age can be a risk factor for certain conditions, such as falls in older adults, being 45 years old alone does not necessarily indicate an increased risk of accidents or injuries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) The stoma protrudes slightly from the abdomen. - A slightly protruding stoma is a normal finding following colostomy surgery and does not require reporting.
B) The stoma bleeds lightly when touched. - Minor bleeding may occur, especially in the immediate postoperative period, and typically resolves without intervention.
C) The stoma appears dark in color. - A dark or dusky stoma may indicate compromised blood supply and should be reported promptly to the provider.
D) The stoma is draining a small amount of liquid stool. - Stoma output varies among individuals and can include liquid stool, which is a normal finding post-colostomy surgery.
Correct Answer is ["A","C","E"]
Explanation
A) Observe the client's skin integrity every 2 hr. - Regular skin assessments are essential to monitor for any signs of skin breakdown or injury related to the use of restraints.
B) Use a square knot to secure the client's restraint to the bed. - A quick-release knot, not a square knot, should be used to secure restraints for easy removal in case of an emergency.
C) Ensure that 2 fingers can be placed between the restraint and the client. - This ensures that the restraint is not too tight, allowing for circulation and preventing injury.
D) Tie the ends of the restraint to the client's bed rail. - Restraints should not be tied to the bed rail as it can increase the risk of injury and entrapment.
E) Pad bony prominences before applying a restraint. - Padding bony prominences helps prevent pressure injuries and discomfort for the client.
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