A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Decreased sense of balance

Nighttime urinary incontinence

Heightened sense of pain

Increased nighttime sleeping

Answer and Explanation

The Correct Answer is A

As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and ﬂexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.

Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be inﬂuenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.

In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.

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Correct Answer is B

Explanation

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

A. "I miss him so much already." B. "I am so angry that this is happening to us." C. "We are planning a trip for next spring." D. "We haven't discussed funeral arrangements."

Correct Answer is A

Explanation

When a hospice nurse is visiting a client who has terminal cancer, the statement "I miss him so much already" by the client's partner should be recognized as an indication of anticipatory grief. Anticipatory grief is the grief that occurs before a loss and can include feelings of sadness, longing, and missing the person who is dying.

Option b is incorrect because anger is a common emotion during the grieving process but does not necessarily indicate anticipatory grief.

Option c is incorrect because planning for the future does not necessarily indicate anticipatory grief.

Option d is incorrect because not discussing funeral arrangements does not necessarily indicate anticipatory grief.

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A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief?

Correct Answer is A

Explanation

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

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