NCLEX-RN
NCLEX RN Fundamental Questions Questions
Extract:
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 2 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
Question 1 of 5
The nurse reviews the assessment data and analyzes the individual's risk for falling. Click to specify whether each assessment finding is a risk factor for falling or not.
| Assessment Findings | Risk Factor | Not a Risk Factor |
|---|---|---|
| Ambulation pattern | ||
| Speech pattern | ||
| Age | ||
| Gender | ||
| Fall history | ||
| Current medications |
Correct Answer: A,C,E,F
Rationale: Ambulation pattern, age (older adults), fall history, and medications (e.g., diazepam) are fall risk factors. Speech pattern and gender are not direct risk factors.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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