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 A
Explanation
Rationale:
A. Negligence involves failing to provide care that a reasonably prudent nurse would provide, such as leaving a shift early without proper handoff or notification, which could compromise patient safety.
B. Battery involves unlawful touching of a patient without consent, which is not applicable in this situation.
C. Slander involves making false spoken statements that harm a person's reputation, which is not applicable in this situation.
D. Libel involves making false written statements that harm a person's reputation, which is not applicable in this situation.
Correct Answer is B
Explanation
A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.
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