A nurse is conducting a psychosocial assessment of an older adult client who has recently retired from work.

Which of the following questions should the nurse ask?

(Select all that apply.).

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.

The correct answer isA, B, and C.

These interventions are appropriate for a client who has impaired tactile sensation due to aging.

• Ais correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.

• Bis correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.

• Cis correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.

• Dis wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging.While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.

• Eis wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging.In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.

Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.

However, some general guidelines are:.

• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.

• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.

• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.

• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.