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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Compassion fatigue: Correct. Compassion fatigue is characterized by emotional exhaustion and a reduced ability to empathize due to prolonged exposure to others' suffering, which fits the nurse’s experience of feeling overwhelmed and difficulty feeling sympathy.
B. Adventitious stress: Incorrect. Adventitious stress refers to stress caused by external, unexpected events such as natural disasters or accidents, not by ongoing exposure to clients' suffering.
C. Prolonged grief disorder: Incorrect. Prolonged grief disorder involves intense and persistent grief following a loss, not the emotional exhaustion or empathy issues described by the nurse.
D. Post-traumatic stress disorder (PTSD): Incorrect. PTSD is characterized by severe anxiety, flashbacks, and intrusive thoughts related to trauma, not primarily by empathy fatigue or feeling overwhelmed by others' suffering.
Correct Answer is C
Explanation
A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
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