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) Romberg test: The Romberg test is used to assess a person’s balance and proprioception by asking them to stand with their eyes closed. It does not evaluate the patency of the ulnar and radial arteries.
B) Rapid alternating movement test: The rapid alternating movement test evaluates motor function and coordination by asking the patient to perform tasks like rapidly alternating hand movements. This test is not related to assessing arterial patency.
C) Tinel test: The Tinel test is used to detect nerve compression or irritation by tapping over a nerve, such as the median nerve at the wrist, to see if it elicits a tingling sensation. It does not assess the patency of the ulnar and radial arteries.
D) Allen test: The Allen test is specifically designed to evaluate the patency of the ulnar and radial arteries. It involves occluding both arteries at the wrist while the patient makes a fist and then releasing one artery to assess blood flow to the hand. This test ensures that there is adequate blood supply to the hand if one of the arteries is compromised.

A. 2 B. 3 C. 4 D. 5

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The test done to evaluate and compare the patency of the ulnar and radial arteries is:

Correct Answer is D

Explanation

A client who suffered a stroke 6 months ago and participating in a rehab program is able to actively move the both lower legs against gravity and some resistance. How should the nurse document this finding using the muscle strength grading scale?

Correct Answer is C

Explanation

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