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 B

Explanation

A. He is able to name objects with which he comes in contact correctly.

Explanation: Being able to name objects correctly indicates intact language and object recognition skills, which are positive aspects of cognitive function.

B. He is constantly checking to see whether what he did is correct.

Explanation: Constantly checking to see whether what he did is correct may be an indicator of anxiety or uncertainty about cognitive performance. While this behavior alone does not confirm cognitive impairment, it raises a question about the individual's confidence or potential challenges in decision-making.

C. He is able to hold a conversation with you.

Explanation: Holding a conversation demonstrates language and communication abilities, suggesting intact cognitive skills for social interaction.

D. His attention span will last as long as the project he is working on.

Explanation: Having an attention span that matches the duration of a project suggests a focused and goal-oriented approach, which can be a positive aspect of cognitive function.

A. Making refreshment stations readily available B. Caloric supplements with the meals C. Providing feeding assistance D. Optimal social supports

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

Explanation

A. Making refreshment stations readily available

Explanation: Making refreshment stations readily available can encourage individuals with dementia to access snacks and beverages independently. This can help ensure a consistent intake of calories and nutrients throughout the day.

B. Caloric supplements with the meals

Explanation: Caloric supplements can provide additional nutrients and energy, especially if the client has difficulty consuming an adequate amount of food during meals. Consultation with a healthcare professional is recommended to determine the appropriate type and amount of supplements.

C. Providing feeding assistance

Explanation: Offering feeding assistance, such as help with cutting food into manageable pieces or providing cueing and encouragement during meals, can support individuals with dementia in maintaining proper nutrition.

D. Optimal social supports

Explanation: Optimal social supports, including family members, caregivers, or support groups, can play a crucial role in monitoring the nutritional status of individuals with dementia. Social interactions during meals can positively impact eating behaviors, and caregivers can provide assistance and encouragement.

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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

In assessing an older adult, you question his cognitive skills when you notice that

Correct Answer is B

Explanation

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)

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

Explanation

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

The OASIS was implemented to provide the format for a comprehensive assessment in the home health care setting. How is this assessment tool used? (Select all that apply.)

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An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

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