The nurse is assessing an older adult client who has osteoporosis and reports frequent falls.

The nurse should ask the client about which of the following factors that could contribute to falls?

(Select all that apply.).

Medications

Vision problems

Home environment.

Thyroid function.

Urinary incontinence.

Answer and Explanation

Correct Answer : A,B,C,E

The correct answer is A, B, C, and E.

The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.

• Medications can increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure. Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.

• Vision problems can impair the ability to see obstacles, judge depth and distance, or adjust to changes in light. Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.

• Home environment can pose safety hazards that can cause tripping, slipping, or losing balance. Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.

• Urinary incontinence can lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls. Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.

Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults. However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.

Normal ranges for thyroid function tests vary depending on the laboratory and the method used. However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.

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Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

Phenytoin (Dilantin) is an anticonvulsant medication that is used to control seizures.

It can have several side effects, some of which are serious and require medical attention.

Here are some explanations for each choice:.

A. Avoid drinking grapefruit juice while taking this medication.

This iswrongbecause grapefruit juice does not interact with phenytoin.However, grapefruit juice can affect the levels of other medications, such as statins, calcium channel blockers, and some antidepressants.

B. Brush your teeth gently with a soft-bristled toothbrush.This isrightbecause phenytoin can causegingival hyperplasia, which is an overgrowth of the gums that can lead to bleeding, infection, and difficulty chewing.

To prevent this, patients should practice good oral hygiene, avoid alcohol and tobacco, and see a dentist regularly.

A. Avoid drinking grapefruit juice while taking this medication B.

Brush your teeth gently with a soft-bristled toothbrush C.

Wear a medical alert bracelet or necklace at all times D.

Stop taking this medication if you develop a rash or fever E.

Have your blood levels checked regularly as directed by your provider

A. Follow up with the primary care provider regularly. B. Avoid alcohol and tobacco use C. Take over-the-counter sleeping pills as needed. D. Engage in physical and mental activities daily. E. Wear glasses and hearing aids if prescribed.

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

Explanation

The correct answer isA, B and D.

Here is why:.

• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.

• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.

• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.

Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.

Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.

Delirium can often be prevented.

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The nurse is assessing an older adult client who has osteoporosis and reports frequent falls. The nurse should ask the client about which of the following factors that could contribute to falls? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for a patient who had a seizure disorder and is prescribed phenytoin (Dilantin). Which of the following instructions should the nurse include? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A nurse is providing discharge instructions to an older adult client who has recovered from delirium and their family caregiver. Which of the following recommendations should the nurse make to prevent recurrence of delirium? (Select all that apply.).

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

Explanation

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A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility. Which of the following interventions should the nurse include in the plan?

The nurse is assessing an older adult client who has osteoporosis and reports frequent falls.

The nurse should ask the client about which of the following factors that could contribute to falls?

(Select all that apply.).