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. This response provides the family member with accurate information about the limited effectiveness of drugs in improving appetite and weight gain, along with the potential for serious side effects. It promotes informed decision-making.
B. Stating that there are no drugs that impact appetite or weight gain is not entirely accurate. Some drugs may have an impact, but the effectiveness varies, and they often come with potential side effects.
C. Blanket's statements that these drugs are not permitted in long-term care facilities are not accurate. The use of medications should be based on individual assessment and treatment plans.
D. Saying "Yes, there are some very effective drugs out there. Your mother should be on one of them" is not an appropriate response. It oversimplifies the situation and may not reflect the individualized approach needed in assessing and addressing nutritional concerns.
Correct Answer is ["A","B","E","F"]
Explanation
A. Functional status
Explanation: Assessing the functional status helps determine the individual's ability to perform daily activities independently. Identifying any decline in function can guide interventions to prevent future falls.
B. Medical history
Explanation: A comprehensive medical history review can reveal any pre-existing conditions, medications, or health issues that may contribute to falls. Understanding the individual's medical background is crucial for effective fall prevention strategies.
C. Financial status
Explanation: Financial status is generally not directly relevant to post-fall prevention assessments. While financial difficulties may have an impact on an individual's ability to access certain resources, it is not a primary consideration in fall prevention assessments.
D. Occupational history
Explanation: Occupational history is not a standard component of a post-fall prevention assessment. The focus should be on functional status and physical abilities rather than specific details of the individual's occupational history.
E. Physical status
Explanation: Evaluating the physical status includes assessing balance, strength, gait, and mobility. Identifying physical impairments can guide targeted interventions to address specific risk factors for falls.
F. Environment
Explanation: Assessing the environment involves identifying potential hazards in the home or care setting that could contribute to falls. Modifying the environment to enhance safety is an important aspect of fall prevention.
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