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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is A.“Do you drive your own car or use public transportation?.” This question is appropriate for the domain ofmode of transportation, which is one of the eight areas of occupational performance assessed by the Lawton Instrumental Activities of Daily Living (IADLs) Scale.The scale evaluates a person’s ability to engage in more complex activities thought necessary for functioning in community settings.

Choice B is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofability to use a telephone.The scale asks about the person’s ability to operate a telephone, dial numbers, and answer calls.

Choice C is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofshopping.The scale asks about the person’s ability to take care of all shopping needs independently, shop for small purchases, or need assistance with shopping.

Choice D is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofmobility.The scale does not assess mobility directly, but it may be inferred from the person’s ability to travel by public transportation or car.

The Lawton IADLs Scale has a summary score that ranges from 0 (low function, dependent) to 8 (high function, independent) for women, and 0 to 5 for men.The score identifies areas of need in regard to care and support.

A. Administer antihypertensive medication as prescribed. B. Elevate the head of bed to 90 degrees. C. Check for bladder distention or fecal impaction. D. Apply a cooling blanket to lower body temperature.

Correct Answer is C

Explanation

The correct answer is C.

Check for bladder distention or fecal impaction.

Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.

It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.

Bladder or bowel distension are the most common triggers of autonomic dysreflexia.

Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.

This can help to eliminate the stimulus and lower the blood pressure.

Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.

The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.

Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.

Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.

Normal ranges for blood pressure vary depending on age, sex, and other factors.

However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.

Normal ranges for heart rate also vary depending on age, activity level, and other factors.

However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.

References:.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a functional status assessment for an older adult client using the Lawton Instrumental Activities of Daily Living (IADLs) Scale. The nurse asks the client about his ability to use transportation. Which of the following questions is appropriate for this domain?

Correct Answer is A

Explanation

The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia. What is the priority nursing intervention?

Correct Answer is C

Explanation

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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.).