Which of the following assessments is most appropriate for evaluating a client's risk of falls due to impaired mobility?

The Braden Scale

The Mini-Mental State Examination

The Timed Up and Go Test

The Glasgow Coma Scale

Answer and Explanation

The Correct Answer is C

A. The Braden Scale: This tool is designed to assess a client’s risk for pressure injury by evaluating factors like sensory perception, activity, and moisture. While useful in skin care planning, it does not measure mobility in relation to fall risk.

B. The Mini-Mental State Examination: This screening tool evaluates cognitive status, including memory, orientation, and attention. Although cognition affects fall risk, the MMSE does not specifically measure mobility or gait performance.

C. The Timed Up and Go Test: This test directly evaluates mobility and balance by timing how long it takes a client to rise from a chair, walk a short distance, and return. It is one of the most appropriate and widely used assessments for predicting fall risk related to impaired mobility.

D. The Glasgow Coma Scale: This tool is used to assess a client’s level of consciousness and neurological function, particularly after head trauma. It does not evaluate mobility, balance, or gait, making it unsuitable for fall risk assessment.

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Correct Answer is D

Explanation

A. Levofloxacin: This fluoroquinolone antibiotic is primarily associated with side effects such as tendon rupture, QT prolongation, and central nervous system disturbances. Nephrotoxicity is not a common adverse effect of levofloxacin.

B. Ofloxacin: Also a fluoroquinolone, ofloxacin has similar side effects to levofloxacin, including gastrointestinal upset and neurologic symptoms. It is not linked to significant nephrotoxicity compared to aminoglycosides.

C. Ceftriaxone: This cephalosporin antibiotic is generally well tolerated and not strongly associated with nephrotoxicity. It may cause biliary sludging or gastrointestinal issues but rarely causes renal injury.

D. Gentamicin: Gentamicin, an aminoglycoside, is well known for its risk of nephrotoxicity due to accumulation in renal tubules. It can cause acute tubular necrosis, particularly with prolonged use or high doses, making it the most nephrotoxic option listed.

A. Administer a sedative at bedtime. B. Lock beds and wheelchairs when not providing care C. Teach balance and strengthening exercises D. Provide information about home safety checks. E. Place the bedside table within the client's reach

Correct Answer is ["B","C","D","E"]

Explanation

A. Administer a sedative at bedtime: Sedatives increase the risk of dizziness, confusion, and impaired coordination, particularly in older adults. This intervention would heighten fall risk instead of preventing it.

B. Lock beds and wheelchairs when not providing care: Locking wheels prevents unintended movement and ensures stability during transfers, which helps reduce the likelihood of falls. This is an essential safety practice.

C. Teach balance and strengthening exercises: Exercises that improve balance, flexibility, and strength enhance mobility and reduce fall risk. Encouraging physical activity supports long-term fall prevention strategies.

D. Provide information about home safety checks: Teaching clients about environmental modifications, such as removing clutter and installing grab bars, empowers them to reduce hazards in their living space and prevent falls.

E. Place the bedside table within the client’s reach: Keeping frequently used items close reduces the need for reaching or stretching, which may cause instability. This simple adjustment supports safety and independence.

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Which of the following assessments is most appropriate for evaluating a client's risk of falls due to impaired mobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following antibiotics is known for its potential to cause nephrotoxicity?

Correct Answer is D

Explanation

A nurse is developing a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse plan to include in the plan? (Select all that apply)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is teaching a client who has chronic kidney disease and a new prescription for epoetin alfa. The nurse should instruct the client to increase dietary intake of which of the following substances?

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