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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should arrange for a video conference with an interpreter who speaks the client's language to provide discharge instructions. This ensures that the client receives accurate and complete information in a language they understand. The other
a. Assistive personnel may not be trained or qualified to provide medical interpretation.
b. Family members may not have the necessary medical knowledge to accurately translate medical information.
d. Simply indicating printed instructions in the client's language may not be sufficient to ensure the client understands the information.
Correct Answer is A
Explanation
The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inflammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inflamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.
Let's now discuss why the other
Options are not the correct answers:
- Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood flow to the area, such as arterial insufficiency, rather than inflammation of the vein.
- Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood flow or decreased oxygenation to the area, which can be caused by factors other than inflammation of the vein.
- Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as fluid overload or localized inflammation, and its presence does not necessarily confirm the presence of phlebitis.
In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inflammation of the vein, which can be caused by various factors including irritation or infection. The other
Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with different underlying conditions or factors.
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