When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

stiffening of the large arteries

rise in the systolic blood pressure

postural orthostatic hypotension

Decline of pacemaker cells in the sino-atrial node

Answer and Explanation

The Correct Answer is C

A. Stiffening of the large arteries: Stiffening of the large arteries is a common age-related change and can contribute to increased systolic blood pressure. While this change can affect cardiovascular function, it does not directly increase the risk of falls as much as other factors.
B. Rise in the systolic blood pressure: An increase in systolic blood pressure often occurs with aging due to arterial stiffening. Elevated systolic blood pressure alone does not directly cause an increased risk of falls but is a part of the broader spectrum of cardiovascular changes.
C. Postural orthostatic hypotension: Postural orthostatic hypotension (OH) is characterized by a significant drop in blood pressure when a person stands up from a sitting or lying position, leading to dizziness or lightheadedness. This condition is common in older adults and significantly increases the risk of falls, as it can cause sudden dizziness and unsteadiness upon standing.
D. Decline of pacemaker cells in the sino-atrial node: The decline of pacemaker cells in the sinoatrial node can lead to bradycardia or irregular heart rhythms, which are related to cardiac function. While this can affect overall cardiovascular health, it does not directly contribute to the risk of falls as much as the sudden changes in blood pressure associated with postural orthostatic hypotension.

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Correct Answer is D

Explanation

A) "Let's stop and take your vital signs": While taking vital signs can be important, it might not address the immediate discomfort the client is experiencing from the deep palpation. This response may not fully address the need to pause the assessment in light of the client’s discomfort.
B) "We can take a break anytime": Offering a break is considerate, but it does not directly address the immediate situation. If the client is already in significant discomfort, it's more appropriate to stop the procedure entirely if the information gathered so far is sufficient.
C) "Keep taking deep breaths; you will be okay": Encouraging deep breathing may help manage some discomfort, but it doesn’t acknowledge the client's need to stop the procedure or the fact that the assessment may have already provided sufficient information.
D) "Let's stop: I have all of the information we need": Stopping the palpation when the client is experiencing pain or discomfort and when enough information has been obtained is the most appropriate response. It shows sensitivity to the client's pain and prioritizes their comfort, while also acknowledging that the assessment may have achieved its purpose.

A. Wear socks when walking around the home. B. Install grab bars in the bathtub. C. Secure rugs with adhesive tape. D. Use nightlights along stairways and walkways. E. Install handrails on both sides of all stairways.

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

Explanation

A) Wear socks when walking around the home: Wearing socks, especially if they have smooth soles, can increase the risk of slipping on hard surfaces. Non-slip footwear is recommended for preventing falls. Therefore, recommending socks for walking may not address the safety concerns effectively.
B) Install grab bars in the bathtub: Installing grab bars in the bathtub is a crucial safety measure for preventing falls and providing support for older adults while bathing. This helps reduce the risk of slips and injuries in a common high-risk area for falls.
C) Secure rugs with adhesive tape: Securing rugs with adhesive tape helps prevent them from slipping, which can significantly reduce the risk of tripping and falling. Loose or unsecured rugs are common hazards in the home environment.
D) Use nightlights along stairways and walkways: Using nightlights along stairways and walkways improves visibility and helps prevent falls during the night. Adequate lighting is essential for older adults to navigate their homes safely.
E) Install handrails on both sides of all stairways: Installing handrails on both sides of stairways provides additional support and stability, which is particularly important for older adults to prevent falls while using stairs. This enhancement helps ensure safer navigation of stairs.

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When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

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