The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Balance

Stride

Flexibility

Speed

Answer and Explanation

The Correct Answer is A

A. Balance:

The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.

B. Stride:

Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.

C. Flexibility:

While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.

D. Speed:

Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.

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

Explanation

A. Pointing to a grimacing face or crying

Explanation: This behavior may indicate pain or discomfort, and it's important to assess and address the underlying cause.

B. Staring off into space

Explanation: Staring off into space may suggest disorientation or confusion. It's essential to evaluate whether this behavior is a manifestation of the client's cognitive impairment or if there are other contributing factors.

C. Aggression

Explanation: Aggression can be a behavioral expression of distress or frustration in cognitively impaired individuals. Identifying triggers and employing appropriate interventions is crucial for the safety of the client and others.

D. Agitation

Explanation: Agitation, restlessness, or pacing may be signs of discomfort, anxiety, or frustration in cognitively impaired individuals. Identifying the cause and implementing strategies to reduce agitation are essential aspects of care.

E. Increased confusion

Explanation: A sudden increase in confusion may indicate an underlying issue, such as an infection, medication side effect, or environmental change. Regular assessment of cognitive status helps in detecting changes and addressing them promptly.

F. Decreased passivity

Explanation: Passivity, or a lack of activity or initiative, is not necessarily a specific symptom commonly associated with cognitive impairment. Observing for changes in behavior, mood, and cognitive status is important, but the term "decreased passivity" is not a standard indicator of cognitive impairment. Instead, it's essential to assess for changes in behavior that may indicate distress or unmet needs.

A. Tell her to use an assistive device until her balance improves. B. Provide information on group exercises for balance training. C. Instruct her to enroll in a general exercise program for 8 weeks. D. Help her to learn how to exercise the core group of muscles

Correct Answer is B

Explanation

A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.

B. Providing information on group exercises for balance training is a suitable intervention.

Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.

Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.

C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.

D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.

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The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

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

Explanation

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

Correct Answer is B

Explanation

In reviewing an older adult's insurance history, you find that he is on Medicaid. What do you know that Medicaid is used for?

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