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 B
Explanation
The correct answer is B.
The client needs assistance with two ADLs.This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding.The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence.The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.
Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.
Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.
Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.
Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.
The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client.For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6.Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.
Correct Answer is ["A","B","D"]
Explanation
The correct answer is A, B, and D.These are some of the strategies to prevent orthostatic hypotension, which is a sudden drop in blood pressure caused by a change in posture, such as when a person stands up quickly.
Some explanations for the other choices are:.
• Choice C is wrong because drinking caffeinated beverages can cause dehydration, which can worsen orthostatic hypotension by reducing the fluid volume in the blood vessels.
• Choice E is wrong because increasing salt intake can raise blood pressure, but it can also cause fluid retention, which can strain the heart and kidneys.People with hypertension, heart failure, or kidney disease should limit their salt intake.
Some normal ranges for blood pressure are:.
• Systolic blood pressure (the top number) should be less than 120 mmHg for most adults.
• Diastolic blood pressure (the bottom number) should be less than 80 mmHg for most adults.
• Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 2 to 5 minutes of standing.
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