Which of the following assessment(s) is/are considered reliable in the older adult? (Select all that apply.)

Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.

Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.

Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.

Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.

Choice A reason:

It is important for the client to document any difficulty starting or stopping the urinary stream as this can indicate potential issues with bladder function or muscle control.

Choice B reason:

Documenting the character of the urine, such as color and odor, can provide valuable insights into potential underlying health issues, such as dehydration or urinary tract infections.

Choice C reason:

The ability to reach a toilet and use it is crucial information as it helps in understanding the client's mobility and accessibility to restroom facilities, which can impact her urinary patterns.

Choice D reason:

Although not listed, it's essential to note that having a bowel movement at the same time can also provide insights into potential underlying issues and patterns related to urinary incontinence.

Choice E reason:

The amount and timing of fluid intake and urine output are imperative to track as they can reveal patterns and potential triggers for urinary incontinence, aiding in the development of an effective management plan.