During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Ask about the circumstances behind the fall(s).

Assess for any injuries the client might have.

Evaluate the client for gait and balance.

Ask about the history or frequency of falls.

Answer and Explanation

Correct Answer : A,D

Choice A reason: Asking about the circumstances behind the fall(s) can help you identify the possible risk factors and causes of the fall(s), such as environmental hazards, medications, chronic conditions, or acute illnesses. Asking about the circumstances can also help you determine the severity and urgency of the situation, and whether the client needs further evaluation or referral.

Choice B reason: Assessing for any injuries the client might have is important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any life-threatening or serious injuries that may require immediate attention. Assessing for injuries is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice C reason: Evaluating the client for gait and balance is also important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any underlying medical conditions that may affect the client's gait and balance. Evaluating gait and balance is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice D reason: Asking about the history or frequency of falls can help you assess the client's fall risk and identify any patterns or trends in the client's fall history. Asking about the history or frequency of falls can also help you tailor the appropriate interventions and prevention strategies for the client.

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Correct Answer is C

Explanation

Choice A reason: Serum sodium levels are not the best determination of hydration in this client, as they can be affected by other factors, such as fluid intake, fluid loss, kidney function, or medication use. Serum sodium levels can be normal, high, or low in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.

Choice B reason: BUN stands for blood urea nitrogen, which is a waste product of protein metabolism that is excreted by the kidneys. BUN is not the best determination of hydration in this client, as it can be influenced by other factors, such as protein intake, liver function, or muscle breakdown. BUN can be high or low in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.

Choice C reason: Urine osmolality is the best determination of hydration in this client, as it measures the concentration of solutes in the urine, which reflects the ability of the kidneys to adjust the urine output according to the fluid status. Urine osmolality can indicate the degree of dehydration or overhydration in a client, as it increases or decreases in response to the fluid balance.

Choice D reason: Urine color is not the best determination of hydration in this client, as it can be affected by other factors, such as food, medication, or infection. Urine color can be dark or light in a dehydrated or overhydrated client, depending on the cause and type of the fluid imbalance.

A. Over-the-counter NSAIDs are generally harmless. B. Stool softeners and laxatives should be used with opioids. C. Opioids are less effective in older clients than in younger clients. D. The dose limit for acetaminophen is difficult to reach for older adults. E. None of the above.

Correct Answer is B

Explanation

Choice A reason: Over-the-counter NSAIDs are generally harmless is not a true statement, as NSAIDs can cause serious adverse effects in older adults, such as gastrointestinal bleeding, renal impairment, hypertension, and heart failure. NSAIDs should be used with caution and under medical supervision in older adults.

Choice B reason: Stool softeners and laxatives should be used with opioids is a true statement, as opioids can cause constipation in older adults, which can lead to discomfort, abdominal pain, fecal impaction, and bowel obstruction. Stool softeners and laxatives can help prevent and treat constipation and promote regular bowel movements.

Choice C reason: Opioids are less effective in older clients than in younger clients is not a true statement, as opioids can have the same or even greater analgesic effect in older adults, depending on the dose, route, and duration of administration. However, opioids can also cause more side effects in older adults, such as sedation, confusion, respiratory depression, and falls. Opioids should be used with caution and under medical supervision in older adults.

Choice D reason: The dose limit for acetaminophen is difficult to reach for older adults is not a true statement, as older adults may be more susceptible to acetaminophen toxicity, especially if they have liver disease, malnutrition, or chronic alcohol use. The dose limit for acetaminophen is 4 grams per day for adults, but it may be lower for older adults or those with risk factors. Acetaminophen should be used with caution and under medical supervision in older adults.

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During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing an elder client for hydration. What is the best determination of hydration in this client?

Correct Answer is C

Explanation

Which of the following statements is true about analgesic medications for older adults?

Correct Answer is B

Explanation

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Which of the following statements is true about analgesic medications for older adults?

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