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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","B","C","D"]

Explanation

These interventions are appropriate for reducing social isolation in older adult clients who live in a long-term care facility because they provide opportunities for social interaction, support, comfort and familiarity.

Choice A is correct because group activities such as games, music, art or exercise can foster a sense of belonging, enjoyment and engagement among older adults.Group activities can also improve physical and mental health, cognitive function and well-being.

Choice B is correct because encouraging family members or volunteers to visit or call the clients regularly can enhance the quality and quantity of social relationships, which can reduce loneliness and isolation.Family members or volunteers can also provide emotional support, companionship and practical assistance to the clients.

Choice C is correct because creating a homelike environment that promotes comfort, safety and privacy can increase the clients’ satisfaction, autonomy and dignity.A homelike environment can also facilitate social interactions among the clients and the staff by providing common areas, personal belongings and familiar objects.

Choice D is correct because assigning consistent staff members who are familiar with the clients’ needs and preferences can improve the continuity and quality of care, as well as the trust and rapport between the clients and the staff.Consistent staff members can also recognize and respond to the clients’ social needs and preferences, and provide personalized interventions.

Choice E is incorrect because providing feedback or recognition for the clients’ achievements or contributions may not be effective in reducing social isolation, unless it is combined with other interventions that promote social interaction and support.Feedback or recognition alone may not address the underlying causes of social isolation, such as lack of meaningful relationships, low self-esteem or poor health.

Normal ranges for social isolation and loneliness are difficult to define, as they depend on various factors such as individual characteristics, cultural norms and measurement tools.However, some indicators of social isolation include having few or no social contacts, participating in few or no social activities, feeling disconnected from others or society, and having low levels of perceived social support.Some indicators of loneliness include feeling unhappy about one’s social situation, feeling left out or unwanted, lacking companionship or intimacy, and having low levels of perceived belongingness or connectedness.

A. HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots. B. HRT can prevent osteoporosis, heart disease and dementia, but it can also cause weight gain, acne and hair loss. C. HRT can enhance sexual function, skin elasticity and memory, but it can also lower the immune system, blood pressure and blood sugar. D. HRT can improve sleep quality, energy levels and mood, but it can also worsen headaches, nausea and bloating.

Correct Answer is A

Explanation

The correct answer is A.

HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots.This answer is based on the evidence from various studies that have shown the benefits and risks of HRT.

Choice B is wrong because HRT cannot prevent osteoporosis, heart disease and dementia, and it does not cause weight gain, acne and hair loss.These are common misconceptions about HRT that are not supported by scientific research.

Choice C is wrong because HRT does not have a significant effect on sexual function, skin elasticity and memory, and it does not lower the immune system, blood pressure and blood sugar.These are also myths about HRT that have no basis in reality.

Choice D is wrong because HRT can improve sleep quality, energy levels and mood, but it can also cause or worsen headaches, nausea and bloating.These are some of the possible side effects of HRT that vary depending on the type, dose and duration of the therapy.

Normal ranges for estrogen and progesterone levels depend on the stage of menopause, the type of HRT and the individual factors of each woman.

Generally, estrogen levels range from 10 to 50 pg/mL (picograms per milliliter) and progesterone levels range from 0.1 to 25 ng/mL (nanograms per milliliter) in postmenopausal women.

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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 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.).

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is teaching an older adult client who has menopause about hormone replacement therapy (HRT). The client asks about the benefits and risks of HRT. What should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is performing a mental status examination on an older adult client who has delirium. Which of the following tools can the nurse use to assess the client’s attention span and concentration?

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A nurse is providing discharge teaching for a patient who had a seizure disorder and is prescribed phenytoin (Dilantin). Which of the following instructions should the nurse include? (Select all that apply.).

The nurse is reviewing the laboratory results of an older adult client who has a urinary tract infection (UTI). Which of the following findings should alert the nurse to a possible complication of UTI in older adults? (Select all that apply.).

According to Erikson’s psychosocial theory, what is the main developmental task of older adults?

A nurse is evaluating a client who is 70 years old for signs of dehydration. Which of the following findings should the nurse expect?

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?

A nurse is providing discharge instructions to an older adult client who has recovered from delirium and their family caregiver. Which of the following recommendations should the nurse make to prevent recurrence of delirium? (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?