Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
History and PhysicalDay 1:
Macular degeneration
Uses a cane to ambulate
Nurses' Notes
Day 3:
Client is discharged to home. Home hazard data is collected by a home health nurse. Home hazard data report:
Unsecured throw rugs over tile floor in kitchen Grab bar present in bathroom
Hot water heater set at 43.3┬░ C (110┬░ F) Nonskid mat in bathtub
Electrical cord on floor over walkway
A nurse is assisting with the care of a client. Exhibits A nurse in a provider's office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.
Correct answer
B,C,E
Rationale
Correct Answer: B,C,E
Rationale:
B: Throw rugs in kitchen increase fall risk due to tripping hazard.
C: Electrical cord over walkway poses a tripping hazard, increasing fall risk.
E: Macular degeneration affects vision, making it harder to detect obstacles, increasing fall risk.
Incorrect:
A: Using a cane indicates mobility aid, not necessarily increased fall risk.
D: Grab bar in the bathroom is a safety feature, reducing fall risk.
Summary: Choices B, C, and E increase fall risk due to tripping hazards and impaired vision, while choices A and D do not directly contribute to fall risk.
Rationale:
B: Throw rugs in kitchen increase fall risk due to tripping hazard.
C: Electrical cord over walkway poses a tripping hazard, increasing fall risk.
E: Macular degeneration affects vision, making it harder to detect obstacles, increasing fall risk.
Incorrect:
A: Using a cane indicates mobility aid, not necessarily increased fall risk.
D: Grab bar in the bathroom is a safety feature, reducing fall risk.
Summary: Choices B, C, and E increase fall risk due to tripping hazards and impaired vision, while choices A and D do not directly contribute to fall risk.