An 82-year-old client has always lived independently in the house that he and his late spouse purchased over 50 years ago. The client has few health problems, but has experienced two falls recently. Which action, by the nurse, is the priority action?

Arrange a family meeting to organize supervision for the client

Elicit what the client perceives to be the causes of and potential solutions to the falls.

Investigate what community resources may be appropriate and available.

Perform a comprehensive musculoskeletal assessment of the client.

Answer and Explanation

The Correct Answer is B

A. Arrange a family meeting to organize supervision for the client:

This option focuses on organizing supervision for the client, assuming that the client requires constant monitoring to prevent falls. While involving family members in the care plan is important, arranging a family meeting might not be the priority until the nurse understands the client's perspective on the falls and explores potential solutions.

B. Elicit what the client perceives to be the causes of and potential solutions to the falls:

This option prioritizes communication with the client to understand their perspective on the falls, including what factors they believe contributed to the falls and what solutions they envision. It respects the client's autonomy and allows them to actively participate in their care planning, which can lead to more effective fall prevention strategies.

C. Investigate what community resources may be appropriate and available:

While community resources can be valuable for supporting older adults, investigating them may not be the priority until the nurse has assessed the client's specific needs and preferences regarding fall prevention. Understanding the client's perspective and potential solutions should come first to tailor the use of community resources accordingly.

D. Perform a comprehensive musculoskeletal assessment of the client:

While assessing musculoskeletal status is important for understanding factors that could contribute to falls, conducting a comprehensive assessment may not be the immediate priority. Instead, focusing on communication with the client to understand their perspective and potential solutions should come first to inform the assessment and subsequent interventions effectively.

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Correct Answer is A

Explanation

Choice A rationale:
Weight gain is the most objective and reliable indicator of improved nutritional status in clients with wasting syndrome. It directly reflects an increase in lean body mass, which is essential for restoring health and function.
A weight gain of 2 lb (1 kg) per month is considered a safe and achievable goal for clients with HIV-III and wasting syndrome. This rate of weight gain promotes gradual replenishment of nutrient stores without overwhelming the body's systems.
While other assessment findings, such as increased food intake or decreased oral discomfort, may be positive signs, they do not necessarily guarantee that nutritional goals have been met. It's possible for a client to consume more calories without experiencing weight gain due to factors such as malabsorption or increased metabolic demands. Similarly, decreased oral discomfort may improve appetite but not ensure adequate nutrient intake.
Choice B rationale:
While eating 90% of meals and snacks is a positive sign, it does not guarantee adequate nutrient intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
The focus of nutritional intervention for wasting syndrome is to increase lean body mass, which is best reflected by weight gain. Eating patterns alone may not accurately capture this progress.
Choice C rationale:
Choosing high-protein foods is important for supporting tissue repair and immune function, but it does not guarantee adequate overall caloric intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
Weight gain is a more comprehensive indicator of improved nutritional status, as it reflects both protein intake and overall caloric balance.
Choice D rationale:
Decreased oral discomfort can improve appetite and facilitate food intake, but it does not guarantee adequate nutrient intake or weight gain. The client may still be consuming insufficient calories or experiencing malabsorption.
Weight gain is a more direct and reliable indicator of improved nutritional status, as it reflects the actual utilization of nutrients for tissue repair and growth.

A. Ensure that medical treatments comply with cultural expectations B. Increase compliance among minority clients C. Provide individualized and culturally sensitive care D. Ensure that clients get the respect customary in their own ethnic group

Correct Answer is C

Explanation

A. Ensure that medical treatments comply with cultural expectations:

- This choice suggests the importance of aligning medical treatments with the cultural expectations of patients. While it's crucial to consider cultural factors when providing healthcare, the primary goal is not just to comply with cultural expectations, but rather to ensure that care is effective, respectful, and aligned with the individual's values and preferences within their cultural context.

B. Increase compliance among minority clients:

- This choice implies a focus on increasing adherence or compliance with medical recommendations among minority clients. While improving compliance is an important aspect of healthcare delivery, it should not be the sole focus when considering cultural factors. Instead, understanding culture should aim to provide culturally competent care that respects the beliefs, values, and preferences of minority clients, thereby fostering trust, engagement, and better health outcomes.

C. Provide individualized and culturally sensitive care:

- This choice accurately reflects the essence of understanding culture in healthcare. Providing individualized and culturally sensitive care involves recognizing and respecting the unique cultural backgrounds, beliefs, values, and preferences of each patient. It emphasizes the importance of tailoring care to meet the specific needs and preferences of diverse older adults within their cultural context, thereby promoting effective communication, engagement, and trust in the healthcare provider.

D. Ensure that clients get the respect customary in their own ethnic group:

- While ensuring respect for clients is indeed important, focusing solely on the respect customary in their own ethnic group may overlook the diversity of cultural backgrounds and preferences within that group. Understanding culture in healthcare goes beyond adherence to specific customs or norms and involves recognizing and respecting the individuality and diversity of each patient's cultural background and preferences. Therefore, while respect is important, the broader goal is to provide individualized and culturally sensitive care that respects the unique cultural perspectives and preferences of each patient.

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An 82-year-old client has always lived independently in the house that he and his late spouse purchased over 50 years ago. The client has few health problems, but has experienced two falls recently. Which action, by the nurse, is the priority action?

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Naxlex Comprehensive Predictor Exams

A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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