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A nurse is assessing an older adult client who has a history of falls.

Which of the following findings should the nurse identify as a risk factor for falls in older adults?

Orthostatic hypotension

Urinary frequency.

Visual impairment

All of the above

Answer and Explanation

The Correct Answer is D

The correct answer is D.

All of the above. All of these findings are risk factors for falls in older adults, according to the literature.

Some explanations for why each choice is a risk factor are:.

A. Orthostatic hypotension: This is a condition where blood pressure drops too much when getting up from lying down or sitting, causing dizziness, lightheadedness, or fainting. This can affect balance and increase the chance of falling.

B. Urinary frequency: This is a condition where one needs to urinate often, sometimes urgently. This can cause rushed movement to the bathroom, especially at night, which can lead to tripping, slipping, or losing balance.

C. Visual impairment: This is a condition where one has reduced or distorted vision, such as due to cataracts, glaucoma, macular degeneration, or diabetic retinopathy. This can affect depth perception, contrast sensitivity, and ability to detect obstacles or hazards in the environment.

Some normal ranges for these conditions are:.

• Orthostatic hypotension: A normal blood pressure change when standing up is less than 20 mmHg systolic (top number) or 10 mmHg diastolic (bottom number).

Orthostatic hypotension is defined as a drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.

• Urinary frequency: A normal urinary frequency is about 4 to 6 times per day, depending on fluid intake and other factors.

Urinary frequency is considered abnormal if it is more than 8 times per day or more than 2 times per night.

• Visual impairment: A normal visual acuity is 20/20 or better with or without correction.

Visual impairment is defined as a visual acuity of 20/40 or worse in the better-seeing eye with best correction possible.

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Correct Answer is A

Explanation

Encourage fluid intake of at least 2 L/day.

This is because adequate hydration can help soften the stool and facilitate its passage through the intestines.Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.

Choice B is wrong because alow-fiber dietcan contribute to constipation by reducing the bulk and water content of the stool.

Fiber helps retain water in the stool and stimulate peristalsis.A high-fiber diet is recommended for clients who have constipation.

Choice C is wrong because astimulant laxativeshould not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa.Stimulant laxatives should be used only as a last resort when other measures fail.

Choice D is wrong becausephysical activitycan help prevent constipation by increasing intestinal motility and blood flow.Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.

Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate.Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.

A. “I will use a walker until I can walk without pain.”. B. “I will avoid crossing my legs or bending my hip more than 90 degrees.”. C. “I will sleep on my back with a pillow between my legs.”. D. “I will apply ice to my hip if it becomes swollen or inflamed.”.

Correct Answer is A

Explanation

The correct answer is A.

“I will use a walker until I can walk without pain.” This statement indicates a need for further teaching because the client should use a walker or other assistive device until they have regained their balance, flexibility and strength, not just until the pain subsides.Using a walker too long or too little can affect the healing process and the stability of the new hip joint.

Choice B is correct because the client should avoid crossing their legs or bending their hip more than 90 degrees to prevent dislocating the new hip joint.

Choice C is correct because the client should sleep on their back with a pillow between their legs to keep the hip in a neutral position and prevent excessive internal or external rotation.

Choice D is correct because the client should apply ice to their hip if it becomes swollen or inflamed to reduce pain and inflammation.The client should also elevate their leg and notify their healthcare provider if they notice any signs of infection, such as fever, chills, redness, warmth or drainage from the incision site.

Normal ranges for hip replacement surgery recovery vary depending on the individual and the type of surgery, but some general guidelines are:.

• The client should be able to walk with a cane or crutches within 2 to 4 weeks after surgery.

• The client should be able to resume most daily activities within 6 to 12 weeks after surgery.

• The client should avoid high-impact activities, such as running, jumping or contact sports, for at least 6 months after surgery.

• The client should have regular follow-up visits with their healthcare provider and physical therapist to monitor their progress and adjust their treatment plan as needed.

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A nurse is assessing an older adult client who has a history of falls. Which of the following findings should the nurse identify as a risk factor for falls in older adults?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is providing discharge instructions to an older adult client who had a hip replacement surgery. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is reviewing the medication list of an older adult client who has delirium. Which of the following medications can contribute to delirium in older adults?

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A nurse is implementing interventions to prevent or reduce social isolation in older adult clients who live in a long-term care facility. Which of the following interventions are appropriate for this setting? (Select all that apply.).

A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool. What does this score indicate?

What are some of the environmental factors that can influence the psychosocial changes in older adults?

A nurse is planning care for an older adult client who has impaired tactile sensation due to aging. Which of the following interventions should the nurse include? (Select all that apply.).

A nurse is assessing an older adult client who has a history of falls.

Which of the following findings should the nurse identify as a risk factor for falls in older adults?