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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. This statement is incorrect as it describes a condition related to diabetes insipidus, not diabetes mellitus.
B. This statement describes the autoimmune process in Type 1 diabetes, not Type 2 diabetes.
C. This statement is inaccurate for Type 2 diabetes; it is more related to acute pancreatitis or Type 1 diabetes.
D. Type 2 diabetes mellitus is characterized by insulin resistance and decreased insulin secretion by the pancreas.

A. The client stands in a tripod position prior to walking. B. The client keeps the elbows in a flexed position. C. The client pushes downward on the handgrips. D. The client places partial weight on the affected leg.

Correct Answer is D

Explanation

A. Standing in a tripod position prior to walking with crutches is a correct stance to maintain balance and stability.
B. Keeping the elbows flexed helps absorb shock during ambulation and is appropriate when using crutches.
C. Pushing downward on the handgrips is necessary to generate upward force and support while using crutches.
D. Placing partial weight on the affected leg while ambulating with crutches using a three-point gait is incorrect and can jeopardize safety by potentially causing injury or instability.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

Correct Answer is D

Explanation

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A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as?

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