The charge nurse at a long-term care facility prepares to teach new staff how to identify fall risk in older adults. Which older adult example should the nurse include that has the greatest risk for falls?

A 68-year-old who has decreased sensation in the lower extremities.

A 73-year-old who takes frequent walking excursions.

An 80-year-old who uses a cane when ambulating.

A 90-year-old who frequently calls for help to change position.

Answer and Explanation

The Correct Answer is A

Geriatric fall risk is multifaceted, involving a decline in proprioceptive feedback and sensory integration that occurs with advanced age or chronic disease. Peripheral neuropathy, often characterized by paresthesia or anesthesia, prevents the individual from detecting foot placement or floor irregularities. This loss of sensory input severely impairs the compensatory postural adjustments required to maintain center of gravity during ambulation.

Rationale:

A. Decreased sensation in the lower extremities represents the greatest risk due to the loss of protective sensation and proprioception. Without tactile feedback, the client cannot accurately perceive the spatial orientation of their limbs, leading to trips and balance failures. This physiological deficit is a more significant predictor of falls than chronological age or the use of assistive devices.

B. A 73-year-old who engages in frequent walking excursions likely possesses higher musculoskeletal strength and better cardiovascular endurance. Regular physical activity actually serves as a protective factor against falls by improving coordination and maintaining muscle mass. This client is considered low risk compared to individuals with focal neurological or sensory deficits.

C. Using a cane indicates that the 80-year-old has recognized their stability needs and is using a compensatory aid to increase their base of support. Assistive devices, when used correctly, provide mechanical stability and reduce the likelihood of a fall occurring. While age is a factor, the proactive use of a cane makes this client safer than one with unmanaged sensory loss.

D. A 90-year-old who frequently requests assistance to change positions demonstrates high safety awareness and cognitive compliance with fall protocols. By seeking help rather than attempting unassisted transfers, the client effectively mitigates the risks associated with advanced frailty. Their dependence on staff for mobility actually acts as a safeguard against accidental falls during movement.

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Correct Answer is ["5"]

Explanation

Convert the concentration first:

8 mg = 8,000 mcg
8,000 mcg in 250 mL

Find mcg per mL:

8,000 ÷ 250 = 32 mcg/mL

Now calculate the volume needed for 152 mcg:

152 ÷ 32 = 4.75 mL

Round to the nearest whole number:

Final Answer:

5 mL

A. The nurses use memory recall to remember which of the three clients is due for analgesic administration in 30 minutes. B. The nurse includes the occurrence of a client fall in the shift report. C. A client is placed on a bed alarm system by a nurse who has not received training on the system. D. Inservice opportunities offer nurses opportunities to practice new skills in a simulation lab. E. A nurse assesses a client's fall risk using evidence-based guidelines.

Correct Answer is ["B","D","E"]

Explanation

Quality and Safety Education for Nurses (QSEN) integrates nursing expertise with evidence-based practice to improve healthcare delivery. It mandates patient-centered care utilizing informatics and quality improvement to mitigate systemic errors and enhance safety through standardized protocols and interdisciplinary collaboration.

Rationale:

A. Reliance on human memory for medication schedules is a failure of the safety competency. QSEN promotes the use of informatics and supportive technology to minimize cognitive load, thereby reducing the probability of human error during complex clinical task management.

B. Transparency in reporting adverse events is essential for quality improvement. Analyzing data from shift reports regarding client falls allows the healthcare team to identify systemic weaknesses and implement corrective measures to prevent future sentinel events or injuries.

C. Operating medical equipment without documented competency validation violates the safety framework. QSEN necessitates that nurses recognize their limitations and utilize system resources or training before employing specialized technology to avoid causing unintentional harm to the client.

D. Simulation laboratories provide a controlled environment for nurses to build clinical competency. This behavior aligns with the QSEN goal of safety, allowing practitioners to refine psychomotor skills and clinical judgment without risking real-time patient outcomes during the learning process.

E. Utilizing validated tools to determine injury risk demonstrates evidence-based practice. By integrating the best current research evidence with clinical expertise, the nurse ensures that interventions, such as fall precautions, are scientifically grounded and clinically effective for the population.

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The charge nurse at a long-term care facility prepares to teach new staff how to identify fall risk in older adults. Which older adult example should the nurse include that has the greatest risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been prescribed norepinephrine 152 mcg. The concentration of norepinephrine is 8 mg mixed in 250 mL of DSW. How many mL should the nurse administer? Round to the whole number.

Correct Answer is ["5"]

Explanation

Final Answer:

The nurse manager is documenting the Quality and Safety Education for Nurses (QSEN) competencies for the nurses on the unit. Which behaviors demonstrate competency of QSEN? Select All That Apply.

Correct Answer is ["B","D","E"]

Explanation

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