Date/Time: 4/11/XXX 1402
Review the electronic health record. What is the client's risk for falls?
Low risk
Moderate risk
High risk
Very high risk
The Correct Answer is A
A. Low risk: Using the Fall Risk Screening Tool, the client scores 3 points for a fall in the past year, 0 points for age (56 years), 1 point for urinary frequency (as the client was walking to the bathroom when they tripped), 0 points for a steady gait, and 0 points for mental status. The total score is 4 points, which places the client in the low-risk category (0–5 points).
B. Moderate risk: Moderate risk requires 6–9 points. With a total score of 4, the client does not meet this threshold.
C. High risk: High risk is defined as 10 or more points, well above the client’s total score.
D. Very high risk: The tool does not include a “very high risk” category; the highest category is “high risk” (≥10 points).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Blood pressure: Blood pressure refers to the overall measurement of force exerted by circulating blood on the walls of arteries, typically recorded as systolic over diastolic pressure. It does not specifically describe the difference between these two values.
B. Pulse pressure: Pulse pressure is calculated as the difference between the systolic and diastolic blood pressure readings. It reflects the force generated by the heart with each contraction and provides information about arterial compliance and cardiac function.
C. Cardiac output: Cardiac output is the volume of blood the heart pumps per minute, determined by heart rate and stroke volume. It does not directly describe the numerical difference between systolic and diastolic pressures.
D. Heart rate: Heart rate is the number of heartbeats per minute and is unrelated to the difference between systolic and diastolic blood pressure. It measures cardiac rhythm, not pressure variance.
Correct Answer is B
Explanation
A. Range of motion that is performed by a healthcare provider: This describes passive range of motion, where the provider moves the client’s joints without active muscle contraction by the client. It is used when clients are unable to move independently.
B. Range of motion that is performed by the client: Active range of motion involves the client voluntarily moving their joints through the full available range. This type of exercise maintains joint flexibility, promotes circulation, and helps preserve muscle strength.
C. The maximum range of motion of healthy joints: While active ROM may approach normal joint limits, it is defined by voluntary movement, not solely by joint health. Maximum joint capacity is not part of the operational definition.
D. An exercise that increases muscle strength and joint mobility: Active ROM may improve circulation and maintain flexibility but does not necessarily significantly increase muscle strength. Strengthening exercises often require resistance beyond active joint motion alone.
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