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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","B","C","E"]

Explanation

The correct answer isA, B, C and E.These interventions are consistent with the best practices for optimizing functional status in the elderly.

Some explanations for the choices are:.

• Choice A is correct because physical activity and exercise can help maintain muscle strength, joint mobility, balance and coordination, which are essential for functional independence and quality of life.

• Choice B is correct because adequate nutrition and hydration can prevent malnutrition, dehydration and electrolyte imbalance, which can impair physical and cognitive function and increase the risk of complications.

• Choice C is correct because managing chronic diseases and medications can prevent complications, adverse effects and polypharmacy, which can affect functional status and increase the need for health care services.

• Choice D is wrong because providing assistive devices and adaptive equipment is not an intervention to improve functional status, but rather to enhance mobility, safety and independence for patients who already have functional limitations.

The question asks for interventions to improve functional status, not to compensate for it.

• Choice E is correct because modifying the environment can reduce hazards, improve accessibility and facilitate self-care, which can promote functional independence and prevent injuries or falls.

The normal ranges for blood glucose and blood pressure for older adults with diabetes and hypertension are:.

• Blood glucose: 80-130 mg/dL before meals and less than 180 mg/dL after meals.

• Blood pressure: less than 140/90 mmHg or individualized based on comorbidities and risk factors.

A. Encourage fluid intake of at least 2 L/day. B. Provide a low-fiber diet. C. Administer a stimulant laxative daily. D. Discourage physical activity.

Correct Answer is A

Explanation

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 alow-fiber dietcan 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 astimulant laxativeshould 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 becausephysical activitycan 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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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.).

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A nurse is implementing interventions to improve the functional status of an older adult client who has diabetes and hypertension. Which of the following interventions should the nurse include? (Select all that apply.).

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

Explanation

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Correct Answer is A

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.).