An older adult comes to the emergency department after falling at home, and reports "I can't walk without losing my balance." Which steps should the nurse implement for this client?
Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion.
Determine symptom onset or when the fall occurred.
Arrange for a transfer immediately to the radiology department.
Perform a comprehensive neurologic assessment.
None of the above.
The Correct Answer is D
Choice A reason: Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion is not the appropriate step, as it is a treatment for acute ischemic stroke, which has not been confirmed in this client. tPA is a clot-busting drug that can restore blood flow to the brain, but it has strict criteria and time window for its use. The nurse should not assume that the client has a stroke without further assessment and diagnosis.
Choice B reason: Determine symptom onset or when the fall occurred is not the appropriate step, as it is not the priority for this client. The nurse should first assess the client's vital signs, neurologic status, and potential injuries from the fall. The symptom onset or fall time may be relevant for the diagnosis and treatment of the underlying cause, but it is not the most urgent information to obtain.
Choice C reason: Arrange for a transfer immediately to the radiology department is not the appropriate step, as it is not the most immediate intervention for this client. The nurse should first stabilize the client's condition, perform a thorough assessment, and obtain orders from the medical provider. The radiology department may be needed for diagnostic tests, such as computed tomography (CT) scan or magnetic resonance imaging (MRI), but it is not the first destination for this client.
Choice D reason: Perform a comprehensive neurologic assessment is the appropriate step, as it can help identify the possible cause of the client's balance problem and rule out a stroke or other serious condition. A neurologic assessment includes checking the client's level of consciousness, orientation, speech, cranial nerve function, motor strength, sensory perception, coordination, and reflexes. The nurse should also monitor the client's vital signs, oxygen saturation, and blood glucose levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because baroreceptor function diminishes with age, and this can affect the regulation of blood pressure and heart rate. Baroreceptors are sensory receptors that detect changes in blood pressure and send signals to the brain to adjust the heart rate and blood vessel tone accordingly. When a person exercises, the blood pressure and heart rate increase to meet the increased oxygen demand of the muscles. When a person stops exercising, the blood pressure and heart rate should decrease gradually to return to the resting state. However, if a person does not cool down properly after exercising, the blood pressure and heart rate can drop suddenly, causing dizziness, fainting, or cardiac arrhythmias. This is especially true for older adults, whose baroreceptors are less sensitive and responsive to blood pressure changes. Therefore, the nurse should instruct the older man to cool down after exercising to prevent these complications.
Choice B reason: This is incorrect because sensory perception diminishes with age, but this is not related to the importance of cooling down after exercising. Sensory perception is the ability to perceive stimuli from the environment, such as sight, hearing, touch, smell, or taste. Sensory perception can decline with age due to various factors, such as age-related changes in the sensory organs, nerve damage, or diseases. This can affect the quality of life, communication, and safety of older adults, but it does not explain why cooling down after exercising is important.
Choice C reason: This is incorrect because cardiac output diminishes with age, but this is not related to the importance of cooling down after exercising. Cardiac output is the amount of blood pumped by the heart per minute, and it depends on the heart rate and the stroke volume. Cardiac output can decline with age due to various factors, such as age-related changes in the heart muscle, valves, or arteries, or diseases. This can affect the ability of the heart to meet the oxygen demand of the body, especially during exercise, but it does not explain why cooling down after exercising is important.
Choice D reason: This is incorrect because mobility capacity decreases with age, but this is not related to the importance of cooling down after exercising. Mobility capacity is the ability to move and perform physical activities, such as walking, climbing stairs, or lifting objects. Mobility capacity can decrease with age due to various factors, such as age-related changes in the muscles, bones, or joints, or diseases. This can affect the functional status, independence, and well-being of older adults, but it does not explain why cooling down after exercising is important.
Correct Answer is C
Explanation
Choice A reason: Aphasia is a language disorder that affects the ability to communicate, not the ability to walk or balance.
Choice B reason: Traumatic brain injury (TBI) is caused by external forces, such as a blow to the head, not by internal factors, such as diseases or deficiencies.
Choice C reason: Gait disturbances are problems with walking or balance that can result from neurological damage affecting the motor system.
Choice D reason: Postprandial hypotension (PPH) is a drop in blood pressure after eating that can cause dizziness or fainting, but it is not directly related to neurological damage.
Choice E reason: Fallophobia is a fear of falling or heights, not a condition caused by neurological damage.
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