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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) 2: A muscle strength grade of 2 indicates that the muscle can move when gravity is eliminated, such as when the limb is supported. However, it does not have enough strength to move against gravity. This grade is not appropriate for the client described, as they can move both lower legs against gravity.
B) 3: A muscle strength grade of 3 means that the muscle can move the joint against gravity but without any additional resistance. This is less than the client’s described ability, as they can move their legs against some resistance.
C) 4: A muscle strength grade of 4 indicates that the muscle can move against gravity and moderate resistance. This matches the client’s ability to actively move both lower legs against gravity and some resistance, making it the correct documentation of their muscle strength.
D) 5: A muscle strength grade of 5 indicates normal muscle strength, where the muscle can move against gravity and full resistance without any signs of fatigue. Since the client is described as moving against some resistance but not full resistance, a grade of 5 would overestimate their current muscle strength.
Correct Answer is A
Explanation
A) Asymmetrical shape: One of the key "ABCD" characteristics of malignant melanoma is asymmetry. Melanomas often have an irregular shape where one half does not match the other, unlike benign moles, which are typically symmetrical. This characteristic helps in distinguishing malignant lesions from benign ones.
B) Diameter less than 6mm: Malignant melanomas are often larger than 6 mm in diameter, especially as they progress. While smaller lesions can still be malignant, a diameter less than 6 mm is not a distinguishing feature for melanoma. Typically, melanomas are identified as growing larger over time.
C) Color is uniform: Malignant melanomas usually exhibit multiple colors or uneven pigmentation rather than uniform color. Uniform color is more characteristic of benign moles. Melanomas can show a mix of colors, including shades of brown, black, and sometimes red or white.
D) Borders well demarcated: Malignant melanoma often has irregular, not well-defined borders. The edges of a melanoma are usually uneven or not clearly defined, unlike benign moles, which typically have smooth, well-demarcated borders.
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