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. "The provider should sign the advance directives before it is valid." This statement is incorrect. Advance directives are valid once they are signed by the client, not the provider. The provider's signature is not required.
B. "The health care proxy is required to approve the client's wishes listed in advance directives." This statement is incorrect. The health care proxy does not have the authority to approve or alter the client's wishes. The proxy is responsible for ensuring that the client's wishes are followed as documented in the advance directives.
C. "The health care proxy can add additional treatments to the advance directives." This statement is incorrect. The health care proxy cannot add or change treatments listed in the advance directives. Their role is to make decisions based on the existing directives.
D. "Advance directives should be documented in the client's medical record." This statement is correct. Advance directives should be documented in the client's medical record to ensure that all healthcare providers are aware of and can adhere to the client's wishes.

A. "This document will ensure that my health care wishes remain confidential." B. "This document will tell others what care I want when I cannot speak for myself." C. "My attorney has to prepare this document for me." D. "My family can change the document if I become mentally incapacitated."

Correct Answer is B

Explanation

A. "This document will ensure that my health care wishes remain confidential." Advance directives are meant to be shared with healthcare providers and family members, not kept confidential.
B. "This document will tell others what care I want when I cannot speak for myself." This statement correctly reflects the purpose of advance health care directives.
C. "My attorney has to prepare this document for me." While an attorney can assist, the document can be prepared without one.
D. "My family can change the document if I become mentally incapacitated." The document cannot be changed by family members once the client is incapacitated.

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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

Naxlex Comprehensive Predictor Exams

A charge nurse is providing an in-service for a group of staff nurses about advance directives. Which of the following statements by a staff nurse indicates the teaching was effective?

Correct Answer is D

Explanation

A nurse is teaching a client about advance health care directives. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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