A nurse is assessing a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?

Choice A rationale:

Administering IV medication via an oral route is a medication error and should be reported.

Choice B rationale:

A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.

Choice C rationale:

Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.

Choice D rationale

An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.

Choice A rationale:

Decreased thickness of tympanic membranes is not a typical physiological change in older adults. Tympanic membranes tend to become thinner and less flexible with age, leading to increased susceptibility to damage, not decreased thickness.

Choice B rationale:

Decreased tinnitus is not a physiological change related to aging. Tinnitus can occur in individuals of all ages and is often associated with various factors such as exposure to loud noises, ear infections, or underlying medical conditions.

Choice C rationale:

Decreased ear wax is not a typical physiological change in older adults. In fact, older adults may experience increased production of earwax, which can lead to hearing problems if not managed appropriately.

Choice D rationale:

Decreased ability to hear high-frequency sounds is a common physiological change in older adult clients. This change, known as presbycusis, is characterized by a reduced ability to hear high-pitched sounds due to changes in the inner ear, including damage to hair cells and changes in the auditory nerves. Presbycusis is a well-documented and expected age-related change in hearing.