A nurse is planning care for an older adult client who has impaired tactile sensation due to aging.
Which of the following interventions should the nurse include?
(Select all that apply.).
Monitor the client’s skin for signs of injury or infection.
Teach the client to avoid exposure to extreme temperatures.
Encourage the client to use assistive devices for mobility and balance.
Provide the client with sensory stimulation such as massage or music.
Advise the client to wear loose-fitting clothing and shoes.
Correct Answer : A,B,C
The correct answer is A, B, and C.
These interventions are appropriate for a client who has impaired tactile sensation due to aging.
• A is 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.
• B is 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.
• C is 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.
• D is 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.
• E is 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Delirium.
The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.
Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.
Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.
Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.
Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.
Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.
Choice C is wrong because seizures are not a common complication of fever in older adults.
Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.
Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.
Fever-induced seizures are more likely to occur in young children than in older adults.
Correct Answer is B
Explanation
Intention tremors and nystagmus.These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body.Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing.Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.
Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.
Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.
Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.
Normal ranges for some of the symptoms mentioned are:.
• Intention tremors: none or minimal.
• Nystagmus: none or minimal.
• Muscle atrophy: none or minimal.
• Fasciculations: none or minimal.
• Flaccid paralysis: none or minimal.
• Areflexia: absent or reduced reflexes.
• Hyperactive reflexes: normal or slightly increased reflexes.
• Spasticity: normal or slightly increased muscle tone.
A. Muscle atrophy and fasciculations B.
Intention tremors and nystagmus C.
Flaccid paralysis and areflexia D.
Hyperactive reflexes and spasticity
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