The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long term care facility.

Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?

The correct answer is choice C - Paresthesia, paralysis, pedal pulses, pallor, and pain.

Choice A rationale:

Clear lung sounds, CPM (continuous passive motion) on. While assessing lung sounds and the

use of CPM after knee replacement is essential, it may not be the most critical information to document in the client's electronic medical record (EMR) compared to other potential complications.

Choice B rationale:

Call bell, side rails, bed in low position, and ambulation aids. These are important safety measures and assistive devices for the client's post-operative recovery. While documenting these measures is important, they are not the most crucial findings to be documented in the EMR.

Choice C rationale:

Paresthesia, paralysis, pedal pulses, pallor, and pain. After a total knee replacement, it is crucial to assess the neurovascular status of the affected leg to identify any potential complications like nerve damage, circulatory impairment, or blood clot formation.

Documenting these assessments in the EMR helps monitor the client's progress and identify any changes that may require immediate intervention.

Choice D rationale:

Blood pressure 138/88, pain scale 7, and respirations 22. While monitoring vital signs and pain levels is important, these parameters are not the top priority in this situation.

Neurovascular assessments are more critical for the early detection of complications.

The correct answer is choicec. Ask the parents to explain what they understand about the child’s diagnosis.

Choice A rationale:

While it is important to support the parents’ decisions, this choice does not address the need for accurate information and understanding about the condition and its management.

Choice B rationale:

Hypospadias does not typically resolve on its own, and delaying surgery can lead to complications such as difficulty with urination and sexual function later in life.

Choice C rationale:

Asking the parents to explain what they understand about the child’s diagnosis ensures that they have accurate information and can make an informed decision about the timing of surgery.This approach also allows the nurse to correct any misconceptions and provide necessary education.

Choice D rationale:

Delaying surgery for hypospadias can lead to complications, including issues with urination and sexual function.It is important to address these potential risks with the parents.