A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.

Electrical cord on floor over walkway.

Uses a cane to ambulate.

Unsecured throw rugs over tile floor in kitchen.

Macular degeneration.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
An electrical cord on the floor over a walkway can pose a tripping hazard, increasing the risk of falls. It’s important to keep walkways clear of any obstacles to prevent falls.
Choice B rationale
Using a cane to ambulate does not necessarily increase the risk of falls. In fact, canes are often used to improve balance and stability, reducing the risk of falls. However, it’s important that the cane is used correctly and is the right height for the individual.
Choice C rationale
Unsecured throw rugs, especially over a slippery surface like a tile floor, can easily cause someone to slip and fall. It’s recommended to secure rugs with non-slip backing or remove them entirely from high-traffic areas.
Choice D rationale
Macular degeneration can lead to vision loss, which can increase the risk of falls. Individuals with vision impairments may not be able to see hazards in their path, making them more prone to falls.

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Correct Answer is A

Explanation

Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.

A. Mottling of the skin in the lower extremities B. Increased blood pressure C. Cheyne-Stokes breathing D. Warm, dry, and pink skin E. Regular respiration

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

Explanation

Choice A rationale
Mottling of the skin, especially in the lower extremities, is a common sign of impending death. This is due to decreased blood flow and can be a sign that the body is starting to shut down.
Choice B rationale
This statement is incorrect. As a person nears death, their blood pressure typically decreases, not increases.
Choice C rationale
Cheyne-Stokes breathing, which is characterized by a pattern of increasing and decreasing respiration with periods of apnea, is a common symptom in the final stages of life.
Choice D rationale
This statement is incorrect. As a person nears death, their skin may become cool to the touch and may appear pale or mottled.
Choice E rationale
Regular respiration is not typically a sign of impending death. In fact, changes in breathing patterns, such as Cheyne-Stokes breathing, are more common.

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A nurse is reviewing a fall risk assessment for a client. Which of the following findings place the client at risk for a fall? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reposition a patient. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assessing a patient who is in the active stage of dying. What are the signs and symptoms of impending death? (Select all that apply)

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

Explanation

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A nurse is reviewing a fall risk assessment for a client.
Which of the following findings place the client at risk for a fall? Select all that apply.