Which factors in the patient care environment should be routinely assessed to decrease the risk of falls? (Select all that apply.)

Choice A reason: The classic signs of elevated glucose levels, polyuria, polyphagia, and polydipsia are rarely present in older adults is true because older adults may have impaired thirst sensation, reduced appetite, or altered renal function that can mask these symptoms. They may also have other chronic conditions or medications that can affect their glucose levels or urine output.

Choice B reason: Older adults tend to metabolize glucose at a faster rate than younger adults is false because older adults usually have a slower metabolism and a reduced insulin sensitivity that can impair their glucose regulation. They may also have less muscle mass and more fat tissue that can affect their glucose utilization.

Choice C reason: Fingerstick glucose monitoring is inaccurate in older adults is false because fingerstick glucose monitoring is a reliable and convenient method to measure blood glucose levels in older adults, as long as they follow the proper technique and calibration. They may also benefit from using devices that have larger displays, voice output, or memory functions.

Choice D reason: There is a higher tolerance for elevated levels of circulating glucose in older adults is false because elevated levels of circulating glucose can cause serious complications in older adults, such as cardiovascular disease, kidney disease, nerve damage, or infections. Older adults may have a higher risk of developing these complications due to their age, comorbidities, or frailty.

Choice A reason: This is the correct answer because the nurse should assess the patient's pain level and location, even if he denies pain. The patient's vital signs indicate that he may be experiencing pain, as increased heart rate, respiration rate, and blood pressure are common physiological responses to pain. Pain can also be masked by other factors, such as fear, anxiety, or stoicism. Therefore, the nurse should ask the patient about his comfort and use a valid pain assessment tool, such as the numeric rating scale or the faces pain scale, to measure his pain intensity.

Choice B reason: This is incorrect because the nurse should not administer an opioid medication by IV route without assessing the patient's pain level and location first. Opioid medications are potent analgesics that can relieve severe pain, but they can also cause serious side effects, such as respiratory depression, sedation, nausea, vomiting, constipation, or dependence. The nurse should follow the principles of pain management, such as using the lowest effective dose, titrating the dose according to the patient's response, and monitoring the patient for adverse effects. The nurse should also consider using non-pharmacological interventions, such as ice packs, elevation, or distraction, to complement the pharmacological therapy.

Choice C reason: This is incorrect because the nurse should not check the surgical dressing for bleeding without assessing the patient's pain level and location first. Checking the surgical dressing for bleeding is an important intervention to monitor the patient's wound healing and prevent infection, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can impair wound healing and increase the risk of complications. The nurse should also obtain the patient's consent and explain the procedure before checking the surgical dressing, as this can cause discomfort and anxiety.

Choice D reason: This is incorrect because the nurse should not report the vital signs to the health care provider without assessing the patient's pain level and location first. Reporting the vital signs to the health care provider is an important intervention to communicate the patient's condition and obtain further orders, but it is not the priority in this scenario. The nurse should first assess the patient's pain and provide appropriate pain relief, as pain can affect the vital signs and the patient's well-being. The nurse should also document the patient's pain assessment and intervention in the medical record, as this can facilitate the continuity of care and evaluation of outcomes.