You are visiting a client in the home to conduct a fall risk assessment. The nurse assess the client and the home for extrinsic risk factors for falls. Which of the following are extrinsic risk factors? (Select all that apply.)
The client uses a cane, but the cane is not the appropriate size for the client
The client has an unsteady gait
The client's home is cluttered
The client is o two different medications that cause orthostatic hypotension
There are no grab bars in the client's bathroom
Correct Answer : A,C,E
A. Using a cane that is not the appropriate size is an extrinsic (environmental or equipment-related) risk factor because it involves improper use of assistive devices.
B. An unsteady gait is an intrinsic factor, related to the individual's physical condition or mobility.
C. A cluttered home presents environmental hazards and is clearly an extrinsic factor that increases the risk of tripping or falling.
D. Taking medications that cause orthostatic hypotension is an intrinsic factor because it relates to internal physiological effects of medication.
E. Lack of grab bars in the bathroom is an extrinsic environmental hazard that limits safety and support during movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Presbyopia is an age-related condition in which the lens of the eye loses elasticity, making it difficult to focus on near objects—this is the most accurate explanation of the condition.
B. Changes in the cornea that increase astigmatism can occur with age, but this is not the cause of presbyopia.
C. A gray ring around the cornea (arcus senilis) is a normal age-related change but is unrelated to presbyopia.
D. An increase in lens opacity refers to cataracts, which is a different condition that affects overall vision, not specifically near vision.
Correct Answer is D
Explanation
A. Sedative-hypnotics are generally not recommended for older adults with dementiadue to risks of increased confusion, falls, and adverse drug effects.
B. While limiting fluids at night can help reduce nocturia, it does not address the core issues of agitation and sleep disruptionrelated to dementia.
C. Individuals with dementia often have limited capacity to understand or retain education, making this intervention ineffective for managing sleep issues.
D. Passive music therapyis a non-pharmacologic, calming interventionshown to improve sleep and reduce agitation in individuals with dementia, making it the most effective and safest option in this context.
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