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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
The correct answer isA, B, and E.
The nurse should instruct the patient to do the following:.
• Trim nails straight across and file edges smoothly.
• Soak nails in warm water before trimming to soften them.
• Report any signs of infection or inflammation around nails.
These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.
Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.
To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.
:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.
Correct Answer is ["A","B","C"]
Explanation
The correct answer isA, B, and C.
These interventions are appropriate for a client who has impaired tactile sensation due to aging.
• Ais correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.
• Bis correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.
• Cis correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.
• Dis wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging.While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.
• Eis wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging.In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.
Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.
However, some general guidelines are:.
• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.
• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.
• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.
• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.
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