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.
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Related Questions
Correct Answer is B
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
Correct Answer is A
Explanation
A. Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls.
B. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
D. Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.
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