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

Answer and Explanation

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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Correct Answer is A

Explanation

A) "I'm glad to have the opportunity to choose what kind of care I receive while I still can." - This statement reflects an understanding of the purpose of advance directives, which is to allow individuals to express their wishes for care while they are still able to do so.
B) "If I want life support, I'll need to sign a separate consent form first." - This statement does not accurately reflect the purpose or process of advance directives.
C) "I can't change my mind about the care I will receive once I sign my living will." - Advance directives can be updated or revoked at any time as long as the individual is of sound mind and able to make decisions.

D) "Once I fill out my living will, there will be a 1-month delay before it is legally binding." - Advance directives typically become legally effective as soon as they are completed and signed, without a waiting period.

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A. deep tendon reflexes 4+ B. Heart rate irregular C. Bowel sounds hyperactive x 4 quadrants D. Generalized weakness with equal bilateral muscle strength and mild leg cramping E. Lungs clear F. Heart rate 95/min G. Alert and oriented to person, place, and time;

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

Explanation

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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

Explanation

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