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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Anger: Anger stage is marked by frustration and resentment, often directed at caregivers, family, or the situation itself. Clients may question why the illness happened to them, but this scenario shows refusal to accept the reality of permanent kidney failure, not anger.
B. Denial: Denial is the refusal to accept the seriousness or permanence of a condition. The client’s belief that their kidneys are working again and that dialysis may no longer be needed reflects avoidance of the reality of end-stage kidney disease, making denial the best match.
C. Depression: The depression stage involves sadness, withdrawal, and hopelessness as the client begins to grasp the full impact of the illness. The client in this case is not expressing despair but instead minimizing the seriousness of the disease.
D. Bargaining: Bargaining is characterized by attempts to negotiate for more time or a different outcome, often expressed as “If I do this, then things will change.” The client is not making deals or promises but rather refusing to accept the condition.
Correct Answer is D
Explanation
A. Intracranial pressure readings: ICP readings are current assessment data and belong in the Assessment segment of SBAR rather than the background. These values help the oncoming nurse interpret the client’s current status but are not part of historical or contextual information.
B. Plan of care changes for upcoming shift: Changes in the plan of care are included in the Recommendation segment of SBAR. This informs the oncoming nurse of anticipated actions but is not part of the client’s background history.
C. Code status: Code status is typically included in the Situation segment, as it is critical for immediate decision-making during emergencies, not background context.
D. Glasgow score: The Glasgow Coma Scale score provides a summary of the client’s neurological status prior to or at the time of the shift report and reflects baseline information relevant to the client’s condition. Including it in the Background segment gives context for current changes and ongoing care.
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