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NCLEX-RN

Category - Safety

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A nurse is reviewing an elderly client’s records. The nurse determines that the risk of the client for falls is increased by which of the following?

Cranial nerve one dysfunction
A blood pressure of 120/90
Urinary tract infection diagnosis
A blood glucose of 100 mg/dl

Explanation

Answer: C - Urinary tract infections have been associated with changes in the sensorium in elderly clients. Cranial nerve eight dysfunction, low blood pressure, and low blood glucose can increase the risk for falls.

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