A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility.

Which of the following interventions should the nurse include in the plan?

Encourage fluid intake of at least 2 L/day.

Provide a low-fiber diet.

Administer a stimulant laxative daily.

Discourage physical activity.

Answer and Explanation

The Correct Answer is A

Encourage fluid intake of at least 2 L/day.

This is because adequate hydration can help soften the stool and facilitate its passage through the intestines. Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.

Choice B is wrong because a low-fiber diet can contribute to constipation by reducing the bulk and water content of the stool.

Fiber helps retain water in the stool and stimulate peristalsis. A high-fiber diet is recommended for clients who have constipation.

Choice C is wrong because a stimulant laxative should not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa. Stimulant laxatives should be used only as a last resort when other measures fail.

Choice D is wrong because physical activity can help prevent constipation by increasing intestinal motility and blood flow. Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.

Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate. Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.

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

Explanation

The correct answer isA, B, C, and E.

The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.

• Medicationscan increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure.Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.

• Vision problemscan impair the ability to see obstacles, judge depth and distance, or adjust to changes in light.Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.

• Home environmentcan pose safety hazards that can cause tripping, slipping, or losing balance.Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.

• Urinary incontinencecan lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls.Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.

Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults.However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.

Normal ranges for thyroid function tests vary depending on the laboratory and the method used.However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.

A. Loss of bone mass and strength B. Loss of muscle mass and strength C. Loss of joint flexibility and range of motion. D. Loss of skin elasticity and moisture.

Correct Answer is B

Explanation

The correct answer isB.

Loss of muscle mass and strength.Sarcopenia is a condition that affects older adults and causes a progressive decline in skeletal muscle mass, strength, and function.This can lead to an increased risk of falls, fractures, disability, and mortality.

Choice A is wrong because the loss of bone mass and strength is calledosteoporosis, not sarcopenia.Osteoporosis is a condition that affects the density and quality of bones, making them more prone to fracture.

Choice C is wrong because loss of joint flexibility and range of motion is calledarthritis, not sarcopenia.

Arthritis is a term that refers to inflammation of the joints, which can cause pain, stiffness, swelling, and reduced mobility.

Choice D is wrong because loss of skin elasticity and moisture is calledskin aging, not sarcopenia.

Skin aging is a process that involves changes in the structure and function of the skin, such as wrinkles, sagging, dryness, and decreased wound healing.

Normal ranges for muscle mass and strength vary depending on age, sex, body size, and physical activity level.However, some general indicators of sarcopenia include:.

• A muscle mass index (muscle mass divided by height squared) below 7.26 kg/m2 for men and 5.45 kg/m2 for women.

• A handgrip strength below 30 kg for men and 20 kg for women.

• A gait speed below 0.8 m/s for both sexes.

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A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility. Which of the following interventions should the nurse include in the plan?

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A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility.

Which of the following interventions should the nurse include in the plan?