The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?

An adult patient who has left arm weakness secondary to a childhood injury.

An elderly patient who requires eye glasses for reading small print on labels and newspapers.

A patient who is confused and experiencing nausea due to a head injury.

A patient who uses the grab bars located in the hospital bathroom.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice D rationale:

Adduction is the movement of a body part toward the midline of the body. When the nurse moves the patient's leg toward the midline of the patient's body, it is an adduction movement of the hip joint. This movement involves bringing the leg back to the body's midline, which is the opposite of abduction, where the leg moves away from the midline.

Choice A rationale:

Flexion refers to the bending of a joint, decreasing the angle between two body parts. This is not the correct term for moving the leg toward the midline; it describes a different movement.

Choice B rationale:

Abduction is the movement of a body part away from the midline of the body. It is the opposite movement to adduction. When the leg moves away from the midline, it is in abduction, not adduction.

Choice C rationale:

Extension refers to the straightening of a joint, increasing the angle between two body parts. It is the opposite movement to flexion. This movement does not involve bringing the leg toward the midline.

A. Format for audiotape report. B. Basis for evaluation of staff members and pay raises. C. Means of identifying risks and corrective measures. D. Support for disciplinary action against healthcare personnel involved.

Correct Answer is C

Explanation

Choice A rationale:

The incident report is not a format for an audiotape report. Incident reports are written records used to document details of an unexpected event or accident, such as a patient fall, to analyze the causes and implement corrective measures.

Choice B rationale:

Incident reports are not primarily used as a basis for evaluating staff members and pay raises. They focus on patient safety and quality improvement, not employee performance evaluations.

Choice C rationale:

The primary purpose of an incident report is to identify risks and corrective measures. Incident reports are essential tools in healthcare facilities to track and analyze adverse events, identify patterns, and implement preventive measures to enhance patient safety. By documenting incidents and analyzing the data, healthcare organizations can identify potential risks and develop strategies to prevent similar occurrences in the future.

Choice D rationale:

While incident reports may be used as a basis for disciplinary actions in some cases, their main purpose is to improve patient safety. Disciplinary actions are taken after a thorough analysis of the incident report, which identifies areas for improvement and preventive measures.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for several patients on a medical unit.Which patient does the nurse identify as being most at risk for falling?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

Correct Answer is D

Explanation

The nurse completes an incident report after a patient falls in the hallway while ambulating.The nurse is aware that the primary purpose of this incident report is what?

Correct Answer is C

Explanation

The nurse explains isometric exercises to the patient on the rehabilitation unit.Which explanation provided by the nurse is accurate?

Which post is most appropriate for a nursing student to put on a social media platform?

What actions taken by a newly licensed nurse are appropriate when documenting on paper? Select all that apply.

What is the nursing priority when logrolling a patient?

The nurse moves the patient's hand toward the inner aspect of the patient's forearm.This range of motion exercise would be documented as what of the wrist?

A patient is experiencing dyspnea.Which intervention(s) would the nurse implement for the patient? Select all that apply.

The nurse is caring for a client who is in the final stages of cancer, is depressed and distant.The client asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

A nurse is caring for a patient who is taking warfarin (Coumadin). Which of the following laboratory values should the nurse monitor regularly?

The nurse is caring for several patients on a medical unit.
Which patient does the nurse identify as being most at risk for falling?