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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answer is A, B, and D.These are some of the strategies to prevent orthostatic hypotension, which is a sudden drop in blood pressure caused by a change in posture, such as when a person stands up quickly.
Some explanations for the other choices are:.
• Choice C is wrong because drinking caffeinated beverages can cause dehydration, which can worsen orthostatic hypotension by reducing the fluid volume in the blood vessels.
• Choice E is wrong because increasing salt intake can raise blood pressure, but it can also cause fluid retention, which can strain the heart and kidneys.People with hypertension, heart failure, or kidney disease should limit their salt intake.
Some normal ranges for blood pressure are:.
• Systolic blood pressure (the top number) should be less than 120 mmHg for most adults.
• Diastolic blood pressure (the bottom number) should be less than 80 mmHg for most adults.
• Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 2 to 5 minutes of standing.
Correct Answer is D
Explanation
The correct answer isD.
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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