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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Extension refers to the straightening of a joint and is the opposite of flexion. It is not the correct term for the described hand movement.
Choice B rationale:
Abduction is the movement of a body part away from the midline of the body. It does not describe the specific movement of the patient's hand toward the inner aspect of the forearm.
Choice C rationale:
Flexion is the bending of a joint, decreasing the angle between two body parts. When the nurse moves the patient's hand toward the inner aspect of the forearm, it is a flexion movement of the wrist.
Choice D rationale:
Adduction is the movement of a body part toward the midline of the body. It is not the correct term for the described hand movement.
Correct Answer is C
Explanation
Choice A rationale:
Weight-bearing activities are not suitable for a patient with contractures, as they may worsen joint stiffness and discomfort. Engaging in weight-bearing activities could lead to further limitations in joint mobility and exacerbate the contractures.
Choice B rationale:
Exercises to strengthen flexor muscles might be beneficial in other contexts, but for a patient with contractures, the focus should be on improving joint mobility and preventing the contractures from worsening. Strengthening exercises do not directly address the issue of limited joint mobility caused by contractures.
Choice C rationale:
Range of motion exercises are essential for patients with contractures. These exercises involve moving joints through their full range of motion to maintain or improve joint flexibility. Regularly performing range of motion exercises prevents further tightening of muscles and joints, thereby preventing the worsening of contractures.
Choice D rationale:
Frequent position changes are important to prevent pressure ulcers and maintain overall comfort, but they do not specifically address the issue of contractures. While position changes are necessary, they are not the primary intervention for managing contractures.
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