which of the following statements from a client may indicate that they are at a higher risk for a fall
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

2. Signs of internal bleeding include all of the following except:

Correct answer: C

Rationale: Vomiting bile is not typically a sign of internal bleeding but is more commonly associated with issues in the gastrointestinal tract. Signs of internal bleeding include painful or swollen extremities, a tender, rigid abdomen, and bruising. Painful or swollen extremities can indicate bleeding from an extremity injury, a tender, rigid abdomen can signal abdominal bleeding, and bruising can result from blood vessel damage. Therefore, the correct answer is 'C: vomiting bile,' as it is not a typical sign of internal bleeding.

3. Which of the following behaviors is least appropriate when dealing with fellow staff members?

Correct answer: C

Rationale: The least appropriate behavior when dealing with fellow staff members is to only report conflicts that interfere with client care. This choice implies ignoring or neglecting other conflicts that may affect team dynamics and the work environment. It is crucial to address and report all conflicts, whether they impact client care directly or not, to maintain a harmonious and effective working relationship within the healthcare setting. Providing positive feedback, constructive criticism, serving as a resource, and offering input for performance evaluations are all important and appropriate behaviors that contribute to a supportive and professional work environment. By focusing solely on conflicts that interfere with client care, essential issues that influence teamwork and overall staff morale may be overlooked, potentially leading to a negative impact on the work environment.

4. A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?

Correct answer: B

Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.

5. Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?

Correct answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate. Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.

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