It has been determined that each one of the following patients is at risk for falling. Which one requires the nurse's priority for ambulation?
a. A 16-year-old with a sprained ankle being discharged from the emergency department
b. A 54-year-old who has taken the initial dose of an antihypertensive medication
c. A 45-year-old postoperative patient up for the first time since knee surgery
d. An 81-year-old who is asthmatic and had a hip replaced 18 months ago
C
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A The 16-year-old with a sprained ankle being discharged from the emergency department is not the priority for ambulation.
B The 54-year-old who has taken the initial dose of an antihypertensive medication is not the priority for ambulation.
C Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all of the options represent a potential risk for falling, the postoperative patient has both prolonged immobility and physical injury (surgery), and so is at greatest risk.
D The 81-year-old who is asthmatic and had a hip replaced 18 months ago is not the priority for ambulation.
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