The nurse is assisting an older adult patient out of bed when suddenly the patient begins to fall. What is the likely cause of the fall?

Fever

A decrease in venous return

Orthostatic hypotension

Dehydration

Answer and Explanation

The Correct Answer is C

A. Fever: Fever can cause weakness or dizziness, but it is not a sudden cause of falling when getting up.
B. A decrease in venous return can contribute to orthostatic hypotension but is not a direct cause on its own.
C. Orthostatic hypotension is a common cause of sudden falls in older adults when they change positions, leading to dizziness or fainting.
D. Dehydration can lead to orthostatic hypotension but is not as direct a cause of sudden falls when getting up as orthostatic hypotension itself.

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Correct Answer is B

Explanation

A. Site of the lesions: The site of the lesions is addressed by the "S" in some mnemonics, but in PQRST, it refers to severity.

B. Severity of the symptoms: In the PQRST mnemonic for pain assessment, "S" stands for severity, referring to how intense or bothersome the symptoms are.

C. Surface area of the lesions: Surface area is not typically included in the PQRST mnemonic but may be relevant for other assessments.

D. Symptomatology of the lesions: Symptomatology encompasses the overall symptoms but is not specifically what "S" represents in PQRST.

A. The darker the patient's skin, the easier it is to assess for color change. B. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. C. Pallor in black-skinned individuals will appear as a pale pink color. D. Baseline skin color should be assessed in areas with the most pigmentation.

Correct Answer is B

Explanation

A. The darker the patient's skin, the easier it is to assess for color change. Darker skin can make it more challenging to assess color changes, such as pallor or cyanosis.
B. To assess rashes and skin inflammation in dark-skinned individuals, the nurse should rely on palpation. Palpation can help detect changes in texture and warmth, which might be less visible on darker skin.
C. Pallor in black-skinned individuals will appear as a pale pink color. Pallor in dark-skinned individuals often appears as an ashen or gray color, not pink.
D. Baseline skin color should be assessed in areas with the most pigmentation. Baseline skin color should be assessed in normally less pigmented areas like palms and soles for accurate assessment.

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The nurse is assisting an older adult patient out of bed when suddenly the patient begins to fall. What is the likely cause of the fall?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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