A nurse on the unit is conducting a fall risk assessment for four clients. The nurse should identify which of the following clients is the greatest risk for a fall.
An adolescent client who has a leg fracture and has been using crutches for the past 2 days
A client with wound on their leg
A client who has a nursing assistant helping him out of bed
An older adult client who is confused and has urinary frequency
The Correct Answer is D
A. Adolescent clients generally possess superior bone density, muscle mass, and proprioceptive coordination compared to older populations. While a leg fracture and crutch use present a mechanical challenge, 2 days of practice allows for significant motor learning. Their risk is lower than those with cognitive impairments because they can follow safety instructions.
B. A simple leg wound without systemic infection or musculoskeletal involvement does not inherently compromise a patient's center of gravity or gait stability. Unless the wound is associated with severe pain that prevents weight-bearing or involves neurological deficits, the patient remains at a baseline risk level. It is not the primary predictor of an impending fall.
C. Having a nursing assistant present during transfers is a standard safety intervention that actively mitigates the risk of falling. This supervised assistance provides physical support and ensures that the patient follows proper body mechanics during the transition from a supine to a standing position. This patient is currently protected by a human safety barrier.
D. This client possesses three significant risk factors: advanced age, cognitive impairment (confusion), and elimination urgency (urinary frequency). Confusion prevents the client from recognizing their physical limitations or remembering to call for assistance before ambulating. Frequency necessitates frequent, urgent trips to the bathroom, which is the most common environment for inpatient falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Tilting the head toward the chest misaligns the cervical spine and shifts the center of gravity forward, increasing the risk of strain. Proper body mechanics require keeping the head erect and the neck in a neutral position to maintain spinal equilibrium during heavy lifting. Poor head positioning can lead to secondary muscle tension in the trapezius and upper back muscles.
B.Keeping the knees straight causes the nurse to bend at the waist, which places the entire load on the small muscles of the lower back. This posture significantly increases the risk of vertebral disc herniation and musculoskeletal injury. Nurses must flex their knees and hips to lower their center of gravity and utilize the powerful gluteal and quadriceps muscles for movement.
C.Keeping the back straight ensures that the spine remains in neutral alignment, allowing the weight of the load to be distributed evenly across the vertebral discs. This position prevents the shearing forces that occur when the spine is curved or twisted under pressure. Maintaining a straight back is a fundamental principle of safe patient handling that protects the nurse from chronic lumbar injuries.
D.Loosening the abdominal muscles leaves the lower spine unsupported during a transfer, increasing the likelihood of injury. Tightening the abdominal muscles, often called "bracing," creates internal core stability and protects the lumbar region from excessive strain. A strong, engaged core act as a natural corset that stabilizes the trunk while the legs perform the actual lifting work.
Correct Answer is A
Explanation
A.Passive range of motion (PROM) involves the nurse moving the client's joints through their full range without the client's active muscle contraction. This intervention is specifically designed to maintain or improve joint flexibility and prevent the development of permanent contractures. It ensures that the synovial fluid is distributed and the connective tissues remain elongated.
B.Bone density is primarily maintained and increased through weight-bearing exercises and active resistance training, which stimulate osteoblastic activity. Passive movement does not provide the necessary mechanical stress on the skeletal system to affect mineral density. While PROM is beneficial for mobility, it is not an effective strategy for preventing osteoporosis or bone loss.
C.Muscle strength requires active contraction against gravity or resistance to hypertrophy the muscle fibers and improve motor unit recruitment. Since the nurse is performing the movement for the client, the client's muscles are not being exercised. Consequently, passive range of motion cannot increase or even maintain muscle strength in a paralyzed or paretic limb.
D.Muscle mass is preserved through active physical activity and nutritional support; passive movements do not prevent the disuse atrophy associated with a stroke. Without the metabolic demands of active contraction, the muscle fibers will naturally decrease in size over time. PROM focuses exclusively on the integrity of the joint capsule and surrounding ligaments rather than volume.
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