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 C

Explanation

A. Being a victim of a crime: This is typically considered an acute stressor as it represents a single, intense event.
B. Motor vehicle accident: This also represents an acute stressor because it is a specific event with a defined beginning and end.
C. Living in poverty: This is an example of chronic stress as it involves ongoing, persistent stress over an extended period of time, affecting multiple aspects of life.
D. Loss of a loved one: While this is a significant stressor, it is often acute because it refers to a specific event. Chronic stress involves continuous or repeated stress over time.

A. Orthostatic hypotension increases a client's risk of a fall. B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. C. Orthostatic hypotension increases a client's risk of a pulmonary emboli D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Correct Answer is A

Explanation

A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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