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. Angioedema: Angioedema is characterized by deep swelling of the skin and mucous membranes, often caused by allergic reactions. It usually affects areas like the lips, eyes, or throat but does not typically present with vesicular eruptions.
B. Actinic cheilitis: Actinic cheilitis results from chronic sun exposure leading to changes in the lips' texture and color. It typically presents as dry, scaly patches or discoloration, not vesicular eruptions.
C. Angular cheilitis: Angular cheilitis involves inflammation and cracking at the corners of the mouth, often due to fungal or bacterial infection. It does not typically present with vesicular eruptions.

D. Herpes simplex: Herpes simplex virus commonly causes vesicular eruptions on the lips and surrounding skin, known as cold sores or fever blisters. These eruptions are characteristic of the herpes simplex infection and align with the description of vesicular eruptions observed in the client.

A. Range of motion B. Diaphragmatic excursion C. Spinous processes D. Spinal deformities

Correct Answer is A

Explanation

A) Range of motion: Lateral bending of the spine is a movement used to assess the range of motion (ROM) of the spine, specifically the flexibility and mobility of the thoracolumbar region. By asking the client to perform lateral bends, the nurse can evaluate the extent to which the client can bend sideways and assess any limitations or discomfort in the movement.
B) Diaphragmatic excursion: Diaphragmatic excursion refers to the movement of the diaphragm during respiration and is assessed through techniques like percussion and auscultation of the lungs. Lateral bending of the spine does not provide information about diaphragmatic movement.
C) Spinous processes: The spinous processes of the vertebrae can be palpated to assess alignment and tenderness, but lateral bending does not specifically assess the spinous processes. It focuses more on the overall mobility of the spine.
D) Spinal deformities: While lateral bending can reveal limitations in spinal movement that might suggest underlying spinal deformities, it is not a primary diagnostic tool for identifying specific deformities. Other assessments, such as inspection and palpation of the spine, X-rays, or physical

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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

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?

Correct Answer is D

Explanation

While assessing a client's musculoskeletal status, the nurse asks the client to perform lateral bends. Which of the following will this movement provide information about?

Correct Answer is A

Explanation

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