Author Question: An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's ... (Read 18 times)

2125004343 · **on:** Jul 22, 2018

An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a fall assessment tool, the nurse knows that which one of the following is the greatest indicator of risk for falls?

a. Confusion
b. Impaired judgement
c. Sensory deficit
d. History of falls

Question 2

After providing care, a nurse charts in the patient's record. Which entry should the nurse document?

a. Appears restless when sitting in the chair
b. Drank adequate amounts of water
c. Apparently is asleep with eyes closed
d. Skin pale and cool

tashiedavis420 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
According to the fall assessment tool, the greatest indicator of risk for falls is a history of falls.
According to the fall assessment tool, the second leading risk factor for falls is confusion.
According to the fall assessment tool, impaired judgement is the fourth leading risk factor for falls.
According to the fall assessment tool, sensory deficit is the fifth leading risk factor for falls.

Answer to Question 2

D
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, B/P 80/50, patient diaphoretic, heart rate 102 and regular. Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as Intake, 360 mL of water is more accurate than Patient drank an adequate amount of fluid.