What is the greatest indicator of risk of fall?
Impaired judgment.
History of falls.
Sensory deficits.
Confusion.
The Correct Answer is B
Choice A rationale
Impaired judgment is a significant factor in falls because it affects a person's ability to assess environmental hazards or their own physical limitations. While cognitive impairment increases the likelihood of an accident, it is often a secondary predictor. Individuals with poor judgment may attempt tasks beyond their physical capacity, but statistically, this individual trait is not as consistently predictive across all populations as the historical record of a previous falling event occurring.
Choice B rationale
A history of falls is statistically the strongest and most reliable predictor of future falling incidents. This is because a previous fall often indicates an underlying, persistent issue such as gait instability, muscle weakness, or a chronic neurological condition that has not been resolved. In clinical risk assessment tools like the Morse Fall Scale, a prior fall is weighted heavily because it demonstrates that the patient's compensatory mechanisms have already failed at least once.
Choice C rationale
Sensory deficits, including visual or auditory impairments, contribute to fall risk by reducing the patient's ability to perceive their environment accurately. Poor depth perception or loss of peripheral vision can lead to tripping over obstacles. While these deficits are important components of a comprehensive risk assessment, they are considered contributing factors rather than the single greatest indicator. Many patients with sensory deficits successfully use compensatory strategies or assistive devices to maintain their safety and balance.
Choice D rationale
Confusion, whether acute delirium or chronic dementia, significantly elevates the risk of falling because the patient may be unable to follow safety instructions or recognize the need for assistance. Confused patients may attempt to climb over bed rails or wander in unfamiliar environments. However, confusion is often intermittent or reversible. Compared to a documented history of falls, it is slightly less predictive of a future event because it does not always capture physical frailty.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Swelling and coolness at the insertion site are classic indicators of infiltration, which occurs when intravenous fluid enters the surrounding subcutaneous tissue instead of the vein. Infiltration can lead to tissue damage or necrosis depending on the infusate. Normal skin temperature should be maintained at the site. Because the fluid is no longer entering the vascular system, the nurse must immediately stop the infusion and restart the access at a different proximal location to ensure safety.
Choice B rationale
The presence of yellow drainage, or purulence, at the insertion site is a significant sign of localized infection or exit site involvement. This indicates that pathogens have potentially bypassed the skin barrier, posing a risk for systemic bacteremia or sepsis. Standard nursing practice requires the immediate removal of the catheter to prevent further microbial proliferation. The site should be treated, and any subsequent intravenous access must be established at a new, uncontaminated site to protect the client.
Choice C rationale
Tenderness and redness along the path of the vein are hallmark signs of phlebitis, which is inflammation of the inner layer of the vein. This can be caused by chemical irritation, mechanical trauma from the catheter, or bacterial presence. Phlebitis is graded on a scale, but any visible redness and pain necessitate stopping the therapy at that site. Failure to do so can lead to thrombus formation or permanent venous scarring, compromising future vascular access options.
Choice D rationale
When an intravenous fluid stop flowing due to arm position, it is often a mechanical issue related to the catheter tip pressing against a vein wall or a valve. This is considered a positional IV rather than a site failure requiring removal. Adjusting the arm or using an arm board typically resolves the flow rate without needing a new puncture. This finding does not inherently indicate infiltration, infection, or phlebitis, so the access site remains viable for use.
Choice E rationale
Pain without any visible or palpable abnormalities like swelling, redness, or warmth may indicate minor nerve irritation or simple discomfort from the tape or dressing. While the nurse should monitor the site closely, isolated pain does not meet the diagnostic criteria for mandatory site rotation or therapy cessation. The nurse should first assess for external causes of discomfort. If no signs of complication develop, the current access can be maintained while continuing to monitor the client.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Choice A rationale
Hypoactive bowel sounds are defined as infrequent sounds, typically fewer than 5 per minute, which can indicate decreased intestinal motility often seen in constipation or after surgery. A rate of 50 bowel sounds per minute is significantly higher than the normal physiological range of 5 to 30 sounds per minute. Therefore, documenting this finding as hypoactive is clinically incorrect and misrepresents the rapid peristaltic activity occurring within the client's gastrointestinal tract.
Choice B rationale
Hyperactive bowel sounds, also known as borborygmi, occur at a rate greater than 30 per minute and reflect increased peristalsis. This rapid movement of contents through the intestines often prevents the adequate absorption of water and electrolytes, leading to the clinical manifestation of diarrhea. A count of 50 sounds per minute is a clear indication of an overactive gut, commonly associated with gastroenteritis, inflammatory bowel disease, or the early stages of a bowel obstruction.
Choice C rationale
Normal bowel sounds are characterized by intermittent gurgles and clicks occurring at a frequency of 5 to 30 times per minute. A rate of 50 sounds per minute falls well outside this expected baseline, indicating an abnormality rather than a healthy state. While flatulence involves the passage of gas, the specific finding of 50 sounds per minute is more directly indicative of the high-velocity fluid and gas movement associated with hyperactive bowel motility and diarrhea.
Choice D rationale
Absent bowel sounds are documented only after listening for a full five minutes in each abdominal quadrant without hearing any sound, usually indicating a paralytic ileus or peritonitis. This condition represents a total lack of peristalsis, which is the exact opposite of the 50 sounds per minute described in the scenario. A paralytic ileus is a surgical emergency where the bowel is stationary, whereas 50 sounds per minute indicates an intense increase in intestinal activity.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.