A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?
Inguinal hernia
Hyperlipidemia
Multiple sclerosis
Hyperthyroidism
The Correct Answer is C
A. Inguinal hernia: While an inguinal hernia can cause discomfort and potential complications, it is not typically considered a significant fall risk.
B. Hyperlipidemia: This condition affects cholesterol levels and is not directly related to an increased risk of falls.
C. Multiple sclerosis: MS can lead to muscle weakness, balance issues, and coordination problems, which significantly increase the risk of falls.
D. Hyperthyroidism: Although hyperthyroidism can cause symptoms like tremors and muscle weakness, it is less directly associated with fall risk compared to multiple sclerosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The goal of hospice care is to prolong life: Hospice care focuses on providing comfort and improving quality of life rather than prolonging life. It is aimed at managing symptoms and supporting patients and families when a cure is no longer possible.
B. Hospice care is limited to clients who are in a health care facility: Hospice care can be provided in various settings, including the patient's home, nursing homes, or hospice facilities. It is not limited to health care facilities.
C. Hospice care is restricted to clients who are terminally ill: Hospice care is specifically designed for individuals who are terminally ill, typically with a prognosis of 6 months or less to live if the disease runs its usual course. This ensures the care is appropriate and focused on end-of-life comfort.
D. Hospice care cannot be discontinued once it is initiated: Hospice care can be discontinued if the patient's condition improves or if they decide to pursue curative treatment. It is not a permanent commitment.
Correct Answer is D
Explanation
A. Anemia: While stress can have various effects on the body, anemia is not specifically a direct manifestation of prolonged stress. It is more commonly associated with nutritional deficiencies or chronic disease.
B. Hypoglycemia: Prolonged stress typically leads to increased levels of cortisol and other stress hormones, which can cause hyperglycemia (elevated blood sugar) rather than hypoglycemia (low blood sugar).
C. Decreased blood pressure: Prolonged stress usually causes increased blood pressure rather than decreased blood pressure. The body's stress response involves the release of hormones that typically raise blood pressure.
D. Impaired immune function: Prolonged stress can lead to immune system suppression, making the body more susceptible to infections and illnesses. This is a well-documented effect of chronic stress and is thus a correct manifestation to include in the teaching.
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