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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?

A.

Inguinal hernia

B.

Hyperlipidemia

C.

Multiple sclerosis

D.

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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Related Questions

Correct Answer is D

Explanation

A. 214: Although this is a negative-pressure room, it is semi-private, which is not ideal for clients with suspected tuberculosis or similar conditions requiring isolation due to airborne transmission.
B. 212: This is a positive-pressure room, which is not suitable for clients with suspected airborne infections, as it could potentially spread the infection to other areas.
C. 216: This is a private, positive-pressure airflow room, which is not appropriate for the client with suspected airborne infection due to potential cross-contamination risks.
D. 208: This is a private, negative-pressure airflow room, which is ideal for clients with suspected airborne infections, such as tuberculosis. Negative-pressure rooms prevent the spread of airborne pathogens to other areas.

Correct Answer is C

Explanation

A. Bronchial airway constriction: During the fight-or-flight response, bronchial airways typically dilate to increase airflow to the lungs, not constrict.
B. Hypoglycemia: The fight-or-flight response typically increases blood glucose levels to provide quick energy, leading to hyperglycemia rather than hypoglycemia.
C. Dilated pupils: Pupils dilate during the fight-or-flight response to enhance vision and perception of potential threats. This is a correct manifestation of the stress response.
D. Decreased blood pressure: The fight-or-flight response usually causes an increase in blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.

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