A nurse is reviewing a newly admitted client's medical record to determine the need to implement fall prevention interventions. The nurse should identify that which of the following findings places the client at risk for a fall?

The client has gastroesophageal reflux disease.

The client is 62 years old.

The client smokes half a pack of cigarettes per day.

The client has urinary incontinence.

Answer and Explanation

The Correct Answer is D

A. The client has gastroesophageal reflux disease. GERD does not typically increase the risk of falls.
B. The client is 62 years old. Age alone does not necessarily indicate a high fall risk, especially if the client is relatively healthy.
C. The client smokes half a pack of cigarettes per day. Smoking is a risk factor for many health issues but is not directly linked to an increased risk of falls.
D. The client has urinary incontinence. This is correct. Urinary incontinence increases the risk of falls, particularly if the client needs to frequently get up quickly to use the bathroom, potentially slipping or tripping.

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Correct Answer is D

Explanation

A. Abdominal distention: Abdominal distention is not a typical manifestation of dysphagia.
B. Rhinitis. Rhinitis is inflammation of the nasal mucous membrane and is not related to dysphagia.
C. Echolalia: Echolalia is the repetition of another's spoken words and is not a symptom of dysphagia.
D. Drooling: This is correct. Drooling is a common manifestation of dysphagia due to difficulty in swallowing saliva

A. Airborne B. Protective environment C. Contact D. Droplet

Correct Answer is D

Explanation

A. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis and varicella, not bacterial meningitis.
B. Protective environment precautions are used for clients with severely compromised immune systems, not for preventing the spread of bacterial meningitis.
C. Contact: Contact precautions are used for infections spread by direct contact with the patient or their environment, such as MRSA or C. difficile, not bacterial meningitis.
D. Droplet: This is correct. Droplet precautions are required for bacterial meningitis as it spreads through large respiratory droplets.

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A nurse is reviewing a newly admitted client's medical record to determine the need to implement fall prevention interventions. The nurse should identify that which of the following findings places the client at risk for a fall?

Nursing Test Bank

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