ATI Nur 231 Fundamentals Exam

Extract:

Question 1 of 5

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

A. A client who is 1 day postoperative and has a nursing assistant helping him out of bed B. An older adult client who is confused and has urinary frequency C. A client with diabetes mellitus who has a leg ulcer D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days

Correct Answer: B

Rationale: The correct answer is B because an older adult client who is confused and has urinary frequency is at the greatest risk for a fall. Confusion can impair judgment and coordination, increasing the likelihood of accidents. Urinary frequency may lead to frequent trips to the bathroom, increasing the risk of falls, especially during nighttime. The other choices are less likely to pose as high of a fall risk.
Choice A involves assistance from a nursing assistant.
Choice C's leg ulcer does not directly increase fall risk.
Choice D's adolescent client using crutches has some mobility impairment but is likely more stable compared to a confused older adult.

Question 2 of 5

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Question 3 of 5

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Question 5 of 5

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ATI Nur 231 Fundamentals Exam | Nurselytic

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