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 D
Explanation
The correct answer is D.
“Social interaction can help me avoid stress and anxiety.” This statement indicates a need for further teaching because social interaction does not necessarily help older adults avoid stress and anxiety.
In fact, some social situations may cause or increase stress and anxiety for some people, especially if they are negative, unpleasant, or conflictual.
Therefore, the nurse should explain to the client that social interaction can help them cope with stress and anxiety, but not avoid them altogether.
Choice A is correct because social interaction can help lower blood pressure and cholesterol levels by reducing the effects of stress hormones and promoting physical activity.
Choice B is correct because social interaction can help boost the immune system by enhancing positive emotions, increasing antibody production, and reducing inflammation.
Choice C is correct because social interaction can help improve memory and learning ability by stimulating brain regions involved in cognition, communication, and social perception.
Normal ranges for blood pressure are less than 120/80 mmHg for adults, and normal ranges for cholesterol are less than 200 mg/dL for total cholesterol, less than 100 mg/dL for LDL cholesterol, and more than 40 mg/dL for HDL cholesterol.
Correct Answer is B
Explanation
The correct answer is B.
The client needs assistance with two ADLs.This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding.The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence.The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.
Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.
Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.
Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.
Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.
The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client.For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6.Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.
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