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 B

Explanation

A) Tension headache: Tension headaches are typically characterized by a dull, aching pain that feels like a tight band around the head. They are often associated with muscle tension and stress, and they generally do not involve nausea, vomiting, or sensitivity to light and sound, which are more indicative of migraines.
B) Migraine headache: The symptoms described—severe pain rated 10 out of 10, nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia)—are classic signs of a migraine headache. Migraines are often intense and can be accompanied by these additional symptoms, making this the most likely diagnosis.
C) Cluster headache: Cluster headaches are extremely painful and typically occur in cyclical patterns or clusters. They are often unilateral (one-sided) and can cause severe pain, redness of the eye, and nasal congestion. While they can be very painful, they are less commonly associated with nausea, vomiting, and sensitivity to light and sound as described in the scenario.
D) Sinus headache: Sinus headaches are associated with sinusitis and typically involve pain and pressure in the forehead, cheeks, or nose area, often accompanied by nasal congestion. They usually do not present with the intensity of pain, nausea, vomiting, and sensitivity to light and sound seen in migraines.

A. lateralization of the sound/vibration to both ears equally B. lateralization of the sound/vibration to the left ear. C. bone conduction(BC) is greater than air conduction (AC) D. lateralization of the sound/vibration to the right ear.

Correct Answer is B

Explanation

A) Lateralization of the sound/vibration to both ears equally: The Weber test is used to assess unilateral hearing loss and would not show equal lateralization in the presence of unilateral sensorineural hearing loss. Equal lateralization would suggest normal hearing or symmetrical hearing loss, which is not the case here.
B) Lateralization of the sound/vibration to the left ear: In sensorineural hearing loss, sound is perceived to lateralize to the unaffected ear. Therefore, with right ear sensorineural hearing loss, the sound will lateralize to the left ear, indicating that the left ear has better hearing capability.
C) Bone conduction (BC) is greater than air conduction (AC): This finding is characteristic of conductive hearing loss, not sensorineural hearing loss. In sensorineural hearing loss, air conduction is typically greater than or equal to bone conduction, but the Weber test focuses on lateralization rather than BC versus AC.
D) Lateralization of the sound/vibration to the right ear: If the sound were to lateralize to the affected ear in sensorineural hearing loss, it would suggest that the affected ear is hearing better, which contradicts the nature of sensorineural hearing loss. The sound will actually lateralize to the better-hearing, unaffected ear.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A patient came with a right ear sensorineural hearing loss. What should the nurse expect while performing the Weber test?

Correct Answer is B

Explanation

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