A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Decreased sense of balance

Nighttime urinary incontinence

Heightened sense of pain

Increased nighttime sleeping

Answer and Explanation

The Correct Answer is A

As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and ﬂexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.

Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be inﬂuenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.

In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.

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Correct Answer is C

Explanation

A.Age alone is not a reliable or unique identifier. Many clients can share the same age, and this information does not sufficiently confirm an individual’s identity. Using age alone could lead to errors, as it lacks specificity.

B.Room numbers are not reliable for client identification because clients may be moved to different rooms or share rooms with others. Using a room number alone could easily lead to a medication error, as it does not confirm the client’s personal identity.

C.Using a photograph is an acceptable form of client identification, especially in settings where clients may not be able to verbally confirm their identity (e.g., clients with dementia). Photographs, when available, are typically included in the client’s medical records and can help ensure correct patient identification to prevent medication errors.

D.Bed numbers, similar to room numbers, are not unique to an individual and may change or be shared in multi-bed rooms. Relying on a bed number could result in giving medication to the wrong client, which is a significant risk to client safety.

A. Rub his hands together to cause friction for at least 10 seconds. B. Turn oﬀ the faucet with a clean, dry paper towel. C. Dry his hands by working from the forearms down to the fingertips. D. Keep his hands above elbow level when washing.

Correct Answer is B

Explanation

The correct answer is that the nurse should turn oﬀ the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.

Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.

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A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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