A nurse is responsible for six patients.
Which of the following patients are at risk for developing peripheral neuropathy (PN)? (Select all that apply.)

Choice A rationale

Decreased visual acuity can increase the risk of falls, which are a common cause of head injuries in older adults. Impaired vision can affect balance and coordination, making it more difficult for an individual to navigate their environment safely.
Choice B rationale
While motor vehicle crashes can certainly lead to head injuries, they are not one of the most common causes of head injuries in older adults. Falls are actually the leading cause of head injuries in this population.
Choice C rationale
Polypharmacy, or the use of multiple medications by a patient, is common in older adults and can increase the risk of falls and, consequently, head injuries. Certain medications can cause side effects such as dizziness or confusion, which can lead to falls.
Choice D rationale
Weakness, particularly in the lower body, can increase the risk of falls and subsequent head injuries in older adults. Lower body weakness can affect an individual’s balance and mobility, making falls more likely.
Choice E rationale
Chronic hypertension can lead to a variety of health complications, including an increased risk of falls and head injuries. Hypertension can cause dizziness and balance problems, which can increase the risk of falls.

Choice A rationale
Administering acetaminophen by mouth for pain control is important, but it is not the first intervention that should be implemented for a client who has had a traumatic fall. Pain management is crucial, but it is not the immediate priority in this situation.
Choice B rationale
Performing a thorough health history is a part of the nursing assessment, but it is not the first intervention in an acute situation such as a traumatic fall. Immediate physical needs and potential injuries need to be addressed first.
Choice C rationale

Preparing for a STAT non-contrast CT scan is the correct answer. After a traumatic fall, it is crucial to quickly assess for potential injuries, especially to the brain. A CT scan can help identify any immediate life-threatening conditions such as bleeding in the brain.
Choice D rationale
Inserting an indwelling urinary catheter to monitor urine output is an intervention that may be necessary depending on the client’s condition, but it is not the first intervention to be implemented after a traumatic fall.