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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not commonly used in clinical practice and does not accurately describe the condition associated with recurring flashbacks of a past traumatic event.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder and is not related to the psychological symptoms described, such as flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after a traumatic event and involves symptoms like flashbacks, but since the traumatic event occurred a year ago, it is more consistent with PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by persistent symptoms such as flashbacks, intrusive memories, and severe anxiety that occur long after the traumatic event, fitting the client's reported symptoms.
Correct Answer is D
Explanation
A. Provide written educational material for the client: While important, this action is not the first step as it assumes the client is ready to receive and understand the information.
B. Ask the client to demonstrate checking their blood sugar: This is a practical step but should come after assessing the client’s readiness to learn and understanding their current knowledge.
C. Identify short-term goals for the client: Goal-setting is crucial but should follow an assessment of the client's readiness to learn to ensure that goals are realistic and tailored to their current level of understanding.
D. Determine the client's readiness to learn: This is the first step in the teaching process as it helps tailor the teaching plan to the client's current state of mind, comprehension level, and willingness to engage with the educational material.
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