Which assessment finding of an older adult living in an assisted-living facility indicates the highest risk for suicide?

Choice A reason: Asking about the circumstances behind the fall(s) can help you identify the possible risk factors and causes of the fall(s), such as environmental hazards, medications, chronic conditions, or acute illnesses. Asking about the circumstances can also help you determine the severity and urgency of the situation, and whether the client needs further evaluation or referral.

Choice B reason: Assessing for any injuries the client might have is important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any life-threatening or serious injuries that may require immediate attention. Assessing for injuries is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice C reason: Evaluating the client for gait and balance is also important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any underlying medical conditions that may affect the client's gait and balance. Evaluating gait and balance is part of the comprehensive fall risk assessment that should be done after the initial screening.

Choice D reason: Asking about the history or frequency of falls can help you assess the client's fall risk and identify any patterns or trends in the client's fall history. Asking about the history or frequency of falls can also help you tailor the appropriate interventions and prevention strategies for the client.

Choice A reason: This is a correct answer because heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. This can cause fluid retention and congestion in the lungs, kidneys, and other organs. Heart failure can also affect the thirst mechanism and the secretion of antidiuretic hormone, which can lead to reduced fluid intake and increased fluid loss. Therefore, heart failure can increase the risk of dehydration in older clients.

Choice B reason: This is a correct answer because nonfunctional impairments are limitations in the ability to perform activities of daily living, such as bathing, dressing, or toileting. Nonfunctional impairments can be caused by various factors, such as cognitive decline, mobility problems, or sensory loss. Nonfunctional impairments can affect the access to fluids, the awareness of thirst, or the ability to swallow. Therefore, nonfunctional impairments can increase the risk of dehydration in older clients.

Choice C reason: This is a correct answer because longitudinal furrows on the tongue are signs of dehydration in older clients. The tongue is a mucous membrane that can reflect the hydration status of the body. Dehydration can cause the tongue to lose its moisture and elasticity, and develop cracks or fissures along its length. Therefore, longitudinal furrows on the tongue can indicate dehydration in older clients.

Choice D reason: This is an incorrect answer because hypertension is not an issue that might put your client at risk for dehydration, but rather a complication of dehydration. Hypertension is the elevation of the blood pressure above the normal range, which can damage the blood vessels and increase the risk of cardiovascular disease. Hypertension can be caused by various factors, such as aging, obesity, smoking, stress, or kidney disease. Dehydration can also cause hypertension, as the loss of fluid can reduce the blood volume and increase the blood viscosity and concentration of sodium. Therefore, hypertension is not a risk factor for dehydration, but a consequence of dehydration.