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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. Participants in PACE programs must be able to perform their own ADLs independently.
Explanation: This statement is generally not true. PACE programs are designed to provide comprehensive and coordinated care for individuals who are frail and meet the criteria for nursing home admission. The emphasis is on maintaining participants in their homes and communities. Participants in PACE programs often have limitations in Activities of Daily Living (ADLs), and the program is designed to support them in these activities.
B. Participants in PACE programs must have been residents in a nursing home prior to enrollment in the PACE program.
Explanation: This statement is generally not true. PACE programs aim to keep individuals out of nursing homes by providing comprehensive healthcare services in a community setting. Participants in PACE programs are often those at risk of nursing home placement due to their health and functional status.
C. Participants in PACE programs must be eligible for either Medicare or Medicaid.
Explanation: This statement is generally true. PACE programs are funded through Medicare and Medicaid. Participants must be eligible for both Medicare and Medicaid to enroll in a PACE program. Medicaid eligibility may vary by state.
D. PACE programs only provide service to individuals who are age 55 and over.
Explanation: This statement is generally true. PACE programs typically serve individuals who are 55 years of age or older. However, the specific age eligibility may vary by state.
E. PACE programs provide services to individuals who meet the criteria for nursing home admission.
Explanation: This statement is generally true. PACE programs are designed for individuals who are at risk of nursing home placement due to their health and functional status. Participants must meet the criteria for nursing home admission to be eligible for PACE services.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Use cool or tepid water: Applying cool or tepid water to the body, such as through a cool bath or damp cloth, can help reduce body temperature.
B. Avoid alcohol: Alcohol can contribute to dehydration, which increases the risk of hyperthermia. It's important to encourage the client to avoid alcoholic beverages during hot weather.
C. Minimize exertion: Exertion in high temperatures can lead to an increase in body heat. Advising the elderly client to minimize physical exertion during hot weather helps prevent overheating.
D. Wear cool clothing such as silk or polyester: Light and breathable fabrics, such as silk or polyester, promote better air circulation and help the body stay cool.
E. Drink plenty of fluids: Staying hydrated is crucial in preventing hyperthermia. Encourage the client to drink plenty of fluids, particularly water, to maintain proper hydration levels.
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