A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?
A client with diabetes mellitus who has a leg ulcer
An adolescent client who has a leg fracture and has been using crutches for the past 2 days
An older adult client who is confused and has urinary frequency
A client who is 1 day postoperative and has a nursing assistant helping him out of bed
The Correct Answer is C
A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.
Correct Answer is B
Explanation
A. Stage 1 hypertension is defined as a systolic BP of 130-139 mm Hg or a diastolic BP of 80-89 mm Hg.
B. Elevated BP is defined as a systolic BP of 120-129 mm Hg and a diastolic BP of less than 80 mm Hg.
C. Stage 2 hypertension is defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher.
D. Normal BP is defined as a systolic BP of less than 120 mm Hg and a diastolic BP of less than 80 mm Hg.
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