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    Hesi rn med surg proctored exam

    Which assessment data reflects the need for the nurse to include the problem, "Risk for falls," in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

    Explanation & Rationale

    A. Recent serum hemoglobin level of 16 g/dL (160 g/L) is within the normal range and does not indicate an increased risk for falls. B. Expressed feelings of depression may affect motivation or activity levels but does not directly increase the risk of falls unless it leads to physical symptoms such as fatigue or unsteady gait. C. Stooped posture with a steady gait might suggest a musculoskeletal issue, but the "steady gait" does not indicate immediate fall risk. D. Opioid analgesic received one hour ago is the most relevant factor because opioids can cause dizziness, sedation, and impaired coordination, all of which increase the likelihood of falls. The timing of the medication further highlights the need for vigilance.

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