ATI RN
ATI RN pharmacology 2023 Questions
Extract:
Nurses' Notes
Vital Signs
1000:
An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.
1400:
An assistive personnel found the client lying on the floor after coming back from the bathroom. Client states, "I'm so sorry. I had to get up to go to the bathroom, and I couldn't wait for someone to help me." Client is awake, alert, and oriented to person, place, and time. Client reports.no pain. Assessment reveals no injury. Client was provided call button and reminded to call for help when getting out of bed Bed alarm activated.
Question 1 of 5
Click to highlight the pieces of information that indicate the client is at risk for falls.
| admitted following a fall down approximately five steps |
| client possibly hit their head and was a little disoriented for a minute or two |
| history of falls and orthostatic hypotension per client's partner |
| uses a walker |
| Client ordered new glasses following an eye exam last week but has not received them yet |
| Lying: 130/90 mm Hg |
| Standing: 98/60 mm Hg |
Correct Answer: A,B,C,D,E,F,G
Rationale:
To determine if a client is at risk for falls, we need to assess various factors that indicate an increased likelihood of falling.
A: Admitted following a fall down approximately five steps - Indicates a recent fall.
B: Client possibly hit their head and was a little disoriented for a minute or two - Suggests potential head injury and disorientation.
C: History of falls and orthostatic hypotension per client's partner - Previous falls and low blood pressure upon standing increase fall risk.
D: Uses a walker - Indicates mobility issues.
E: Client ordered new glasses but has not received them yet - Vision impairment can contribute to falls.
F: Lying: 130/90 mm Hg - High blood pressure can lead to dizziness and falls.
G: Standing: 98/60 mm Hg - Low blood pressure when standing is a risk factor for falls.
Selecting all options A to G provides a comprehensive assessment of fall risk factors for the client.
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