The nurse teaches a client about the effects of cold therapy on an injury.
Which statement by the client indicates that the teaching has been effective?

Choice A rationale

While being 70 years old is an advanced age, age alone is a less specific predictor of fall risk than functional or physiological impairments. Many 70-year-olds are independent and have high mobility. While being transferred from a long-term care unit suggests a potential for frailty, it is not a primary, high-risk indicator compared to acute physiological instability or a proven history of falls. It is a factor but not a definitive high-risk category.

Choice B rationale

Taking antibiotics is generally not considered a high-risk factor for falls unless the medication causes specific side effects like severe dizziness or ototoxicity. Most standard antibiotics do not impair balance, gait, or cognitive function significantly enough to place a client in a high-risk category. Standard falls assessments, such as the Morse Fall Scale, do not typically weight antibiotic use as a primary risk factor like they do for sedatives or diuretics.

Choice C rationale

Orthostatic hypotension is a significant risk factor for falls. It is defined as a drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within three minutes of standing. This sudden drop causes cerebral hypoperfusion, leading to dizziness, lightheadedness, and syncope. Clients with this condition are at extreme risk of falling during transitions from a lying or sitting position to standing.

Choice D rationale

While the risk of falling generally increases with age, being older than 60 is a very broad category and does not automatically place a client in the high-risk group. Many individuals over 60 maintain excellent balance and strength. Evidence-based fall assessment tools usually look for more specific clinical indicators, such as gait disturbances, cognitive impairment, or specific medical conditions, rather than using a chronological age cutoff of 60 as a sole high-risk marker.

Choice E rationale

A history of multiple falls is one of the strongest predictors of future falls. It indicates an underlying issue with balance, gait, strength, or environmental safety that has already resulted in incidents. Clinically, this history suggests that the client’s compensatory mechanisms are failing. This makes them a high-priority for fall prevention interventions because the statistical probability of a repeat event is significantly higher than for someone who has never fallen.

Choice A rationale

Encouraging the client to keep trying to speak while the tracheostomy tube is in place and the cuff is inflated can lead to extreme frustration and physical exhaustion. Because air is diverted through the tube rather than passing over the vocal cords, vocalization is physiologically impossible or severely muffled for many. Forcing the effort without a speaking valve can cause unnecessary stress and anxiety for a patient already dealing with a compromised airway.

Choice B rationale

Avoiding communication is detrimental to the patient's psychological well-being and safety. Clients with tracheostomies are often highly anxious due to their inability to vocalize needs or fears. Neglecting communication can lead to feelings of isolation, helplessness, and the potential for life-threatening needs to go unaddressed. A nurse must prioritize finding ways to maintain a connection to ensure the patient feels heard, safe, and involved in their own plan of care.

Choice C rationale

Providing alternative communication methods is the standard of care for patients with expressive barriers. Using tools like whiteboards, picture boards, or simple hand gestures allows the patient to convey urgent needs, such as pain or difficulty breathing, effectively. This intervention reduces patient anxiety and empowers them to participate in their care. It also ensures that the nursing staff can accurately assess the patient's condition despite the temporary loss of verbal speech capabilities.

Choice D rationale

While the family can provide emotional support, the nurse should not rely on them as the primary interpreters of clinical needs. The nurse is responsible for establishing a direct and reliable communication channel with the patient to ensure accurate assessment and safety. Relying on third parties can lead to misinterpretations of the patient's symptoms or desires. Direct communication tools ensure the patient's autonomy is respected and that the information gathered is medically reliable and timely.