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. Sub-acute care is more intensive than traditional nursing home care.
Explanation: Sub-acute care is generally more intensive and focused on providing specialized, short-term medical care and rehabilitation services. It is designed for individuals who require a higher level of care than what is typically provided in traditional nursing home settings.
B. Sub-acute care and nursing home care are identical.
Explanation: This statement is incorrect. Sub-acute care and nursing home care serve different purposes. Sub-acute care is typically provided for individuals recovering from acute medical conditions or surgeries, while nursing homes often cater to individuals with chronic illnesses or long-term care needs.
C. Sub-acute care is reimbursed by either Medicaid or private pay.
Explanation: This statement is not entirely accurate. Sub-acute care may be reimbursed by a variety of sources, including Medicare, private insurance, and, in some cases, Medicaid. The reimbursement sources can vary based on the specific circumstances and the services provided.
D. Professional nursing staff levels are the same as those in traditional nursing home settings.
Explanation: This statement is generally incorrect. Sub-acute care settings often have a higher ratio of skilled healthcare professionals, including nurses and therapists, compared to traditional nursing homes. This higher level of staffing is necessary to meet the more intensive medical and rehabilitation needs of sub-acute care patients.
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.
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