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

Answer and Explanation

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.

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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.

A. Night lights B. Excess clutter C. Loose carpeting on the floors D. Railings on the stairway E. The use of a cane

Correct Answer is ["B","C"]

Explanation

A. Night lights

Explanation: Night lights can enhance visibility during nighttime, reducing the risk of falls. The nurse may actually recommend using night lights strategically to illuminate pathways, especially in areas like hallways and bathrooms.

B. Excess clutter

Explanation: Excess clutter on floors can increase the risk of tripping and falling. Removing or organizing clutter helps create a safer environment for the older adult.

C. Loose carpeting on the floors

Explanation: Loose or wrinkled carpeting poses a tripping hazard. The nurse may recommend securing or replacing loose carpeting to prevent falls.

D. Railings on the stairway

Explanation: Railings on stairways are important safety features that provide support and stability. The nurse would likely recommend maintaining or installing railings to enhance stair safety.

E. The use of a cane

Explanation: If prescribed by a healthcare professional, the use of a cane can improve stability and balance for an older adult. The nurse may not recommend eliminating the use of a cane but may instead ensure that the client is using it correctly and that it is in good condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

Correct Answer is A

Explanation

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.)

Correct Answer is ["B","C"]

Explanation

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?

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

What are the benefits associated with telehealth technology? (Select all that apply.)

Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

Which of the following statements are true about Medicare-part 8 supplemental insurance? (Select all that apply.)

The nurse assesses an older adult's cognitive status using a standard assessment instrument. Which of the following are cognitive assessment tools? (Select all that apply.)

To prevent malnutrition in older clients with dementia, which of the following would benefit your client? (Select all that apply.)