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. Difficulty moving the upper extremities may be a result of the stroke but is not a direct complication of immobility.
B. Difficulty hearing some types of sounds is not a typical complication of immobility.
C. Stiffness in the lower extremities can occur but is less urgent than skin breakdown.
D. A reddened area over the sacrum indicates pressure injury, a common and serious complication of immobility that requires immediate attention.
Correct Answer is B
Explanation
Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.
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