A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?
Unsteady gait
Report of short-term memory loss
Hearing loss
Report of frequent constipation
The Correct Answer is A
A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.
A. Ensuring safety and preventing falls is a priority.
B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
Correct Answer is D
Explanation
A. While some clients may be receptive to a scientific perspective, cultural beliefs and practices can significantly influence health-related decisions and behaviors.
B. Assigning clients to specific cultural categories can lead to stereotyping and may not account for the individual variations within a cultural group.
C. Disease and illness can indeed be influenced by cultural factors, including beliefs about health and healing practices.
D. The meaning of behavior can vary widely across cultures, and understanding the cultural context is crucial for providing culturally competent care.
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