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"]
Explanation
A. To improve the quality of care
Explanation: The OASIS assessment is designed to gather information about a patient's health status, functional abilities, and service needs. This information is crucial for developing individualized care plans and providing high-quality care.
B. To evaluate the level of client disability
Explanation: OASIS includes items that assess various aspects of a patient's health, including their functional abilities and disabilities. This evaluation helps healthcare providers understand the client's level of disability and tailor care accordingly.
C. To improve communication about the individual
Explanation: OASIS serves as a standardized tool for collecting and communicating essential information about a patient's health and care needs. This promotes effective communication among healthcare providers, ensuring that everyone involved in the patient's care has access to relevant and consistent information.
D. To serve as a guide for reimbursement
Explanation: OASIS is used in the home health care setting to guide reimbursement. The data collected through OASIS is used to determine the patient's case-mix classification, which, in turn, influences the reimbursement rates for home health services.
Correct Answer is B
Explanation
A. Encouraging the client to use a cane when ambulating.
Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.
B. Keeping the side rails up on the client's bed at night.
Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.
C. Keeping several low wattage night lights on in the evening.
Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.
D. Installing wooden railings on the stairway to the bathroom.
Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.
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