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.).

The correct answer isD.

All of the above.

The nurse should take all of the actions listed to provide effective pain management for the older adult client who has depression and chronic pain in his lower back.

• Choice Ais correct because assessing the pain using a valid and reliable pain scale is essential for determining the severity and impact of pain, as well as monitoring the response to treatment.

• Choice Bis correct because administering analgesic medications as prescribed can help reduce pain and improve function.

The nurse should also monitor for effectiveness and side effects, especially in older adults who may have altered drug metabolism, polypharmacy, and increased risk of adverse events.

• Choice Cis correct because providing non-pharmacological interventions can enhance pain relief, reduce medication use, and address the biopsychosocial aspects of pain.

Massage, heat or cold therapy, relaxation techniques, and distraction are some examples of non-pharmacological interventions that can be used for chronic pain in older adults.

• Choice Dis correct because it includes all of the above actions, which are part of a multimodal approach to pain management that is recommended by clinical guidelines.

4 7 A multimodal approach can improve pain outcomes, reduce side effects, and address the complex needs of older adults with chronic pain.

A. Assess the location, intensity, quality and duration of the pain using a pain scale B.

Administer analgesic medications as prescribed and monitor for effectiveness and side effects C.

Provide non-pharmacological interventions such as massage, heat or cold therapy, relaxation techniques or distraction D.

All of the above

The correct answer is D.

Digit Span Test (DST).

The DST is a tool that can be used to assess the client’s attention span and concentration by asking them to repeat a series of digits forward and backward (Martin, 1990).

The DST is part of the Mini-Mental State Examination (MMSE), which is a broader tool that covers other domains of cognitive functioning, such as orientation, memory, language, and visuospatial skills (Folstein et al., 1975).

Choice A is wrong because the MMSE is not a specific tool for attention span and concentration, but rather a general screening tool for cognitive impairment.

Choice B is wrong because the Confusion Assessment Method (CAM) is a tool that can be used to diagnose delirium, but not to assess attention span and concentration.

The CAM focuses on four features of delirium: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness (Inouye et al., 1990).

Choice C is wrong because the Clock Drawing Test (CDT) is a tool that can be used to assess visuospatial skills and executive function, but not attention span and concentration.

The CDT requires the client to draw a clock face with numbers and hands indicating a specific time (Shulman et al., 1986).

Normal ranges for the DST vary depending on the age and education level of the client, but generally a score of 5 or more digits forward and 4 or more digits backward is considered normal (Martin, 1990).