The nurse is conducting an admission interview and assessment on ...

[bcretired]

The nurse is conducting an admission interview and assessment on a cognitively impaired, unco-operative client for the risk for injury. Which of the following options will most likely provide the information to confirm the diagnosis?
 
  1. Base the degree of risk on observable data at the time of the client's current hos-pital admission.
  2. Closely monitor the client's behavior and habits until risk for injury can be rea-sonably determined.
  3. Make certain critically sound assumptions are based on the client's developmental stage and current cognitive stasis.
  4. Interview the client's family, friends, and/or caregivers regarding prehospitaliza-tion risk factors.

Question 2

Which of the following clients is at greatest risk for injury related to medical diagnoses and con-ditions?
 
  1. A history of asthma and alcohol abuse
  2. A history of heart failure and urinary urgency
  3. A history of hypertension and wearing corrective lenses
  4. A history of chronic bronchitis and impaired hearing

[hramirez205]

Answer to Question 1

ANS: 4
In many cases family members are important resources in assessing a client's fall risk. Families often are able to report on the client's level of confusion and ability to ambulate.

Answer to Question 2

ANS: 2
This client is likely using diuretics that increase the frequency of voiding and result in the client having to use toilet facilities more often. Falls often occur with clients who have to get out of bed quickly because of urinary urgency.

[bcretired]

TYSM

[CAPTAINAMERICA]

Excellent