A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?
Age-related motor deficiencies that result in self-neglect
Age-related neurosensory changes that diminish awareness of temperature changes
Delirium-related to an acute illness that is affecting body heat production
Cognitive changes that diminish the individual's awareness of temperature changes
The Correct Answer is B
A. Age-related motor deficiencies that result in self-neglect.
Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.
B. Age-related neurosensory changes that diminish awareness of temperature changes.
Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.
C. Delirium related to an acute illness that is affecting body heat production.
Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.
D. Cognitive changes that diminish the individual's awareness of temperature changes.
Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Pointing to a grimacing face or crying
Explanation: This behavior may indicate pain or discomfort, and it's important to assess and address the underlying cause.
B. Staring off into space
Explanation: Staring off into space may suggest disorientation or confusion. It's essential to evaluate whether this behavior is a manifestation of the client's cognitive impairment or if there are other contributing factors.
C. Aggression
Explanation: Aggression can be a behavioral expression of distress or frustration in cognitively impaired individuals. Identifying triggers and employing appropriate interventions is crucial for the safety of the client and others.
D. Agitation
Explanation: Agitation, restlessness, or pacing may be signs of discomfort, anxiety, or frustration in cognitively impaired individuals. Identifying the cause and implementing strategies to reduce agitation are essential aspects of care.
E. Increased confusion
Explanation: A sudden increase in confusion may indicate an underlying issue, such as an infection, medication side effect, or environmental change. Regular assessment of cognitive status helps in detecting changes and addressing them promptly.
F. Decreased passivity
Explanation: Passivity, or a lack of activity or initiative, is not necessarily a specific symptom commonly associated with cognitive impairment. Observing for changes in behavior, mood, and cognitive status is important, but the term "decreased passivity" is not a standard indicator of cognitive impairment. Instead, it's essential to assess for changes in behavior that may indicate distress or unmet needs.
Correct Answer is C
Explanation
A. Decreased serum albumin levels can be an indicator of protein malnutrition, but it may not reflect overall nutritional status comprehensively. It is more specific to protein status.
B. Decreased vitamin D levels are related to a specific nutrient (vitamin D) and may indicate a deficiency in that vitamin, but it doesn't provide a broad assessment of overall nutritional status.
C. Unintentional weight loss is a key indicator of potential nutritional deficit.
Unintentional weight loss is a significant concern, especially in older adults, as it can be indicative of various underlying health issues, including malnutrition. It is a more general indicator of overall nutritional status.
D. Anorexia lasting more than 24 hours may contribute to weight loss, but it is a symptom rather than a direct measure of nutritional status. Unintentional weight loss encompasses a broader view of changes in body weight that may signal nutritional deficits.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.