The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?
a. Stride
b. Speed
c. Balance
d. Flexibility
C
Using the Get-Up-and-Go test, the quality of the older adult's movements is assessed. The nurse instructs the individual to rise from a chair, walk, and return to the chair and be seated. The stride is not specifically assessed in this test, although it is an aspect of gait and can be a factor in bal-ance. The older adult's speed is not assessed in this test. Flexibility is not specifically assessed in this test, although it can be an important factor in balance.
You might also like to view...
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond?
a. "Diarrhea is expected; that's how your body gets rid of ammonia." b. "You may take Kaopectate liquid daily for loose stools." c. "Do not take any more of the medication until your stools firm up." d. "We will need to send a stool specimen to the laboratory."
Which nursing activities do not meet the standard of care? Select all that apply
a. Failure to notify a physician about a child's worsening condition b. Calling the supervisor about staffing concerns c. Delegating assessment of a new admit to the Unlicensed Assistive Personnel (UAP) d. Asking the Unlicensed Assistive Personnel (UAP) to take vital signs e. Documenting that a physician was unavailable and the nursing supervisor was notified
Which of the following statements is considered to be part of this rapid screen?
An 88-year-old retired piano teacher comes for evaluation of fatigue. You notice that her clothes are hanging loosely off her frame and that she has lost 15 pounds. She is unaware of this. Her husband of 63 years died a few months ago. You ask the patient to complete a Rapid Screen for Dietary Intake. A) I eat more than two meals per day. B) I drink one glass of alcohol every day. C) Without wanting to, I have lost or gained 10 pounds in the last 6 months. D) I eat with at least one other person most of the time.
Which hemoglobin is made from oxidized ferric iron (Fe3+) and lacks the ability to bind oxygen?
a. Deoxyhemoglobin b. Oxyhemoglobin c. Methemoglobin d. Glycosylated hemoglobin