An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?

Has stable vital signs.

Holds abdomen tightly.

Is not verbalizing.

Moves during sleep.

Answer and Explanation

The Correct Answer is B

Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.

Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.

Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.

Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.

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

Explanation

Choice A reason: This assessment is reliable in the older adult because the skin turgor at the sternum is less affected by age-related changes in skin elasticity and hydration than other sites, such as the forearm or the hand. The skin turgor at the sternum can indicate the fluid status of the older adult, as well as the presence of dehydration or edema.

Choice B reason: This assessment is reliable in the older adult because orthostasis, or a drop in blood pressure when changing positions, is a common condition in this population. Orthostasis can be caused by various factors, such as medications, dehydration, anemia, or autonomic dysfunction. Orthostasis can increase the risk of falls, dizziness, syncope, or cardiovascular complications in the older adult.

Choice C reason: This assessment is not reliable in the older adult because sunken eyes are not a specific sign of dehydration in this population. Sunken eyes can be a normal age-related change in the facial structure, or a result of other factors, such as weight loss, malnutrition, or chronic illness. Sunken eyes can also be influenced by the lighting, the angle of observation, or the presence of glasses or contact lenses.

Choice D reason: This assessment is not reliable in the older adult because decreased urine output is not a sensitive indicator of dehydration in this population. Decreased urine output can be influenced by various factors, such as renal function, fluid intake, medications, or environmental conditions. Decreased urine output can also be a sign of other conditions, such as urinary tract infection, urinary retention, or renal failure.

A. Improper assistive device use contributes to older adult falls. B. Older adults save money by adopting assistive devices from their friends. C. A walker can be used when climbing stairs. D. Cane tips should be smooth. E. None of the above.

Correct Answer is A

Explanation

Choice A reason: Improper assistive device use contributes to older adult falls is a true statement, as it is supported by evidence from web search results. According to the Age Space guide to assistive technology for the elderly, "it is important to ensure that the device is used correctly and safely, as improper use can increase the risk of falls and injuries." Similarly, according to the AAFP article on mobility assistive device use in older adults, "improper use of assistive devices can lead to falls, injuries, and decreased mobility."

Choice B reason: Older adults save money by adopting assistive devices from their friends is not a true statement, as it is not recommended by experts. According to the AAFP article on mobility assistive device use in older adults, "borrowing devices from friends or family members is not advised because devices may not be properly fitted or maintained, and may not meet the patient's needs."

Choice C reason: A walker can be used when climbing stairs is not a true statement, as it is not safe or feasible. According to the NICHD article on types of assistive devices and their use, "walkers are not designed for use on stairs or escalators."

Choice D reason: Cane tips should be smooth is not a true statement, as it is contrary to the best practice. According to the AAFP article on mobility assistive device use in older adults, "cane tips should have a nonskid surface to prevent slipping."

Choice E reason: None of the above is not the correct answer, as there is one choice that is a true statement about assistive devices to aid older adults with impaired mobility.

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An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment(s) is/are considered reliable in the older adult? (Select all that apply.)

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

Explanation

Which of the following is a true statement about assistive devices to aid older adults with impaired mobility?

Correct Answer is A

Explanation

Which of the following statements is true about dysarthria?

The nurse notices that an older adult’s urine is concentrated. Which step should the nurse implement next?

Compared with acute pain, which of the following statements is true of persistent pain?

Which are potential results of end-organ damage from chronic hypertension? (Select all that apply.)

Which of the following assessments should be included in a post-fall prevention assessment of an older adult? (Select all that apply)

A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?

Which of the following is an important consideration about the skin of an older adult person?

In a long-term care facility, a nurse is having a discussion with the nurse aides about ways to deal with dementia clients who are uncooperative with mouth care. Appropriate methods to use include which of the following?