A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?
Age-related motor deficiencies that result in self-neglect
Age-related neurosensory changes that diminish awareness of temperature changes
Delirium-related to an acute illness that is affecting body heat production
Cognitive changes that diminish the individual's awareness of temperature changes
The Correct Answer is B
A. Age-related motor deficiencies that result in self-neglect.
Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.
B. Age-related neurosensory changes that diminish awareness of temperature changes.
Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.
C. Delirium related to an acute illness that is affecting body heat production.
Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.
D. Cognitive changes that diminish the individual's awareness of temperature changes.
Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Constipation.
Explanation: Constipation is a common side effect of opioid medications like morphine. Older adults, particularly those on bed rest or with reduced mobility, are already at an increased risk of constipation. Morphine further contributes to this risk by slowing down bowel motility. Preventive measures such as promoting adequate hydration, encouraging fiber intake, and considering stool softeners can help prevent constipation in this scenario.
B. Poor solid food intake.
Explanation: While monitoring and addressing poor solid food intake are important for overall nutritional status, it may not be the immediate priority related to morphine use and postoperative care.
C. Poor liquid intake.
Explanation: Ensuring adequate fluid intake is important for overall hydration, but constipation is a more specific and immediate concern associated with opioid use.
D. Diarrhea.
Explanation: Diarrhea is not a common side effect of morphine and is less likely to be the priority for preventive care in this situation. Constipation is a more anticipated concern when opioids are prescribed.
Correct Answer is C
Explanation
A. Provide a urinal and drinking water.
Explanation: While providing a urinal and drinking water is important for the client's comfort and hydration, it may not directly address the risk of falls in this situation.
B. Call for someone to bring the sign.
Explanation: Bringing a fall risk sign is a secondary measure and not as immediate as instructing the client to use the call bell. The priority is to ensure the client's safety by addressing the need for assistance promptly.
C. Instruct the client to use the call bell for help.
Explanation: Instructing the client to use the call bell for help is a crucial intervention to ensure that the client can request assistance when needed. Promptly responding to the call bell allows healthcare providers to assist the client with activities such as getting out of bed, using the bathroom, or reaching personal items without the risk of falls. Educating and encouraging clients to use the call bell empowers them to seek assistance and promotes their safety.
D. Ensure he can reach his personal items.
Explanation: Ensuring the client can reach personal items is part of providing a comfortable environment but may not prevent falls. The critical factor in fall prevention is promoting communication and the ability to request assistance in a timely manner.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.