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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Post-traumatic stress disorder (PTSD) is a stress-related disorder that can occur after a person experiences a traumatic event. Symptoms can include flashbacks of the traumatic event, which the patient reports experiencing.
Choice B rationale
Episodic acute stress is a type of stress that occurs in response to specific situations or events. It does not typically involve flashbacks of a traumatic event.
Choice C rationale
Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine. While stress can exacerbate symptoms of IBS, it is not a stress-related disorder in the sense of being a psychological response to stress.
Choice D rationale
Acute stress disorder (ASD) is a stress-related disorder that can occur in response to a traumatic event. However, ASD symptoms occur immediately after the traumatic event and typically resolve within a month. Since the patient reports experiencing flashbacks of a traumatic event that occurred a year ago, ASD is not the correct answer.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Repentance is not typically included in the five stages of grief as outlined by psychiatrist Elisabeth Kübler-Ross.
Choice B rationale
Bargaining is one of the five stages of grief. It often involves the individual making deals or promises to a higher power in an attempt to reverse or lessen the loss.
Choice C rationale
Depression is a stage of grief where the individual may experience intense feelings of sadness, hopelessness, and despair.
Choice D rationale
Acceptance is the final stage of grief, where the individual begins to accept the reality of their loss.
Choice E rationale
Anger is a stage of grief where the individual may feel intense anger towards the situation, themselves, or others.
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