The nurse knows that which of the following is not used to assess fall risk?
a. Glasgow Falls Scale
b. Johns Hopkins Hospital Fall Assessment Tool
c. Morse Fall Scale
d. Hendrich II Fall Risk Model
ANS: A
The Glasgow is a coma scale used to measure level of consciousness, not falls. The rest are scales used to assess the risk for falls in patients.
You might also like to view...
A nurse is educating a woman on the use of denosumab (Prolia). What information should the nurse provide?
A. "Return in 6 months for another injection." B. "Take this medication on an empty stomach." C. "Take this medication with milk or food." D. "You may have increased night sweats."
When a client who has Hodgkin's lymphoma is having radiation therapy or chemotherapy, it is important for the nurse to:
a. encourage a fluid intake of at least 2,500 mL b. encourage increased activity when possible c. provide a low-calorie diet d. provide a high-carbohydrate diet
How is retching different from vomiting?
a. Nausea is not present in retching but is in vomiting. b. Nausea is not present in vomiting but is in retching. c. With retching, no vomiting occurs. d. With vomiting, no retching occurs.
A nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate on the basis of gender, age, race, or religion. Which guiding principle of recovery has this nurse employed?
A. Recovery is culturally based and influenced. B. Recovery is based on respect. C. Recovery involves individual, family, and community strengths and responsibility. D. Recovery is person-driven.