During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Ask about the circumstances behind the fall(s).

Assess for any injuries the client might have.

Evaluate the client for gait and balance.

Ask about the history or frequency of falls.

Answer and Explanation

Correct Answer : A,D

Choice A reason: Asking about the circumstances behind the fall(s) can help you identify the possible risk factors and causes of the fall(s), such as environmental hazards, medications, chronic conditions, or acute illnesses. Asking about the circumstances can also help you determine the severity and urgency of the situation, and whether the client needs further evaluation or referral.

Choice B reason: Assessing for any injuries the client might have is important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any life-threatening or serious injuries that may require immediate attention. Assessing for injuries is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice C reason: Evaluating the client for gait and balance is also important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any underlying medical conditions that may affect the client's gait and balance. Evaluating gait and balance is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice D reason: Asking about the history or frequency of falls can help you assess the client's fall risk and identify any patterns or trends in the client's fall history. Asking about the history or frequency of falls can also help you tailor the appropriate interventions and prevention strategies for the client.

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Correct Answer is ["A","B"]

Explanation

Choice A reason: Sudden onset of symptoms is a sign of hyperthyroidism, as it indicates a rapid increase in thyroid hormone levels that can cause a thyroid storm, a life-threatening condition that requires immediate medical attention. Symptoms of a thyroid storm may include fever, agitation, confusion, sweating, nausea, vomiting, diarrhea, and chest pain.

Choice B reason: Atrial fibrillation is a sign of hyperthyroidism, as it indicates an irregular and fast heartbeat that can result from the excess stimulation of the heart by thyroid hormones. Atrial fibrillation can increase the risk of blood clots, stroke, and heart failure.

Choice C reason: Cold intolerance is not a sign of hyperthyroidism, but rather a sign of hypothyroidism, a condition where the thyroid gland produces too little thyroid hormone. Cold intolerance means feeling cold even in warm environments, due to the reduced metabolic rate and heat production.

Choice D reason: Constipation is not a sign of hyperthyroidism, but rather a sign of hypothyroidism, a condition where the thyroid gland produces too little thyroid hormone. Constipation means having difficulty passing stools, due to the slowed intestinal motility and digestion.

Choice E reason: Heart failure is not a sign of hyperthyroidism, but rather a complication of hyperthyroidism, a condition where the thyroid gland produces too much thyroid hormone. Heart failure means the inability of the heart to pump enough blood to meet the body's needs, due to the increased workload and damage to the heart muscle.

A. Grab bars in place B. Appropriate footwear C. Outdoor grounds D. All four bed rails raised E. None of the above

Correct Answer is ["A","B"]

Explanation

Choice A reason: Grab bars in place are important for preventing falls, as they provide support and stability for the patient when moving around the room, especially in the bathroom. Grab bars can help the patient maintain their balance and avoid slipping or tripping.

Choice B reason: Appropriate footwear is important for preventing falls, as it can reduce the risk of slipping, sliding, or stumbling. Appropriate footwear should fit well, have non-skid soles, and be comfortable and easy to put on and take off.

Choice C reason: Outdoor grounds are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they are not part of the indoor setting where most falls occur. However, outdoor grounds may pose a fall hazard for patients who go outside for recreation or therapy, and should be checked for uneven surfaces, obstacles, or slippery conditions.

Choice D reason: All four bed rails raised are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they may actually increase the risk of falls and injuries. Bed rails may create a false sense of security, encourage the patient to climb over them, or entrap the patient between the rails and the mattress. Bed rails should be used only when indicated and with the patient's consent.

Choice E reason: None of the above is not the correct answer, as there are two factors in the patient care environment that should be routinely assessed to decrease the risk of falls.

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During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with hyperthyroidism. Which signs and symptoms indicate hyperthyroidism? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

Which factors in the patient care environment should be routinely assessed to decrease the risk of falls? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement?

Which of the following is the most important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of heart failure (HF) in older adults?

The nurse assists an older adult man who is diagnosed with type 2 diabetes mellitus to improve his glucose control. Which of the following instructions does the nurse give to this individual when he plans to walk more than usual in one day?

Which disorder would the nurse suspect in a patient complaining of intense headaches, bloodshot eyes, and blurred vision? This is considered a medical emergency.

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

An older adult diagnosed with Type II DM who is being treated with insulin wants to increase his activity level and begin a walking program. What recommendations should the nurse provide to this client?

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse’s priority for preventive care?

According to Healthy People 2020, older adults have been identified as a priority, addressing goals to improve dental health. Identify the correct dental health goals for older adults. (Select all that apply.)