A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Inguinal hernia

Hyperlipidemia

Multiple sclerosis

Hyperthyroidism

Answer and Explanation

The Correct Answer is C

A. Inguinal hernia: While an inguinal hernia can cause discomfort and might require surgical intervention, it is not a primary risk factor for falls compared to other conditions.
B. Hyperlipidemia: Elevated lipid levels are primarily a risk factor for cardiovascular issues and do not directly affect balance or mobility, making it less relevant as a fall risk.
C. Multiple sclerosis: This condition affects the central nervous system and can lead to muscle weakness, balance issues, and coordination problems, increasing the risk of falls.
D. Hyperthyroidism: While hyperthyroidism can have various health effects, it does not directly contribute to fall risk as significantly as multiple sclerosis does.

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Correct Answer is A

Explanation

A. Provide educational material written at an eighth-grade reading level: This ensures that the educational material is accessible and understandable for clients, facilitating better comprehension and retention of information.
B. Turn on the television in the client's room: This is not conducive to effective teaching and may distract the client from the important information being provided.
C. Use technical language in the educational session: Using technical language can confuse clients and hinder their understanding. It is better to use plain language to ensure clarity.
D. Start with the most important information: While prioritizing information is important, the initial focus should be on assessing the client's understanding and tailoring the teaching to their specific needs before covering critical details.

A. Droplet B. Protective C. Contact D. Airborne

Correct Answer is B

Explanation

A. Droplet: Incorrect. Droplet precautions are used for infections spread through respiratory droplets, such as influenza or meningitis, not for immunocompromised clients undergoing stem-cell transplants.
B. Protective: Correct. Protective precautions, also known as neutropenic precautions or reverse isolation, are necessary for clients who are immunocompromised, such as those who have had a stem-cell transplant. These precautions include using barrier protection to prevent infection due to the client's weakened immune system.
C. Contact: Incorrect. Contact precautions are used for infections spread by direct or indirect contact with contaminated surfaces or items, such as Clostridium difficile, not for immunocompromised patients.
D. Airborne: Incorrect. Airborne precautions are used for infections that spread through the air over long distances, such as tuberculosis or measles, and are not specifically needed for clients with compromised immunity post-transplant.

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A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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