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A nurse is assessing an older adult client who has a history of falls.

Which of the following findings should the nurse identify as a risk factor for falls in older adults?

Orthostatic hypotension

Urinary frequency.

Visual impairment

All of the above

Answer and Explanation

The Correct Answer is D

The correct answer is D.

All of the above. All of these findings are risk factors for falls in older adults, according to the literature.

Some explanations for why each choice is a risk factor are:.

A. Orthostatic hypotension: This is a condition where blood pressure drops too much when getting up from lying down or sitting, causing dizziness, lightheadedness, or fainting. This can affect balance and increase the chance of falling.

B. Urinary frequency: This is a condition where one needs to urinate often, sometimes urgently. This can cause rushed movement to the bathroom, especially at night, which can lead to tripping, slipping, or losing balance.

C. Visual impairment: This is a condition where one has reduced or distorted vision, such as due to cataracts, glaucoma, macular degeneration, or diabetic retinopathy. This can affect depth perception, contrast sensitivity, and ability to detect obstacles or hazards in the environment.

Some normal ranges for these conditions are:.

• Orthostatic hypotension: A normal blood pressure change when standing up is less than 20 mmHg systolic (top number) or 10 mmHg diastolic (bottom number).

Orthostatic hypotension is defined as a drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.

• Urinary frequency: A normal urinary frequency is about 4 to 6 times per day, depending on fluid intake and other factors.

Urinary frequency is considered abnormal if it is more than 8 times per day or more than 2 times per night.

• Visual impairment: A normal visual acuity is 20/20 or better with or without correction.

Visual impairment is defined as a visual acuity of 20/40 or worse in the better-seeing eye with best correction possible.

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Correct Answer is ["A","B","C","E"]

Explanation

The correct answer isA, B, C, and E.

The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.

• Medicationscan increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure.Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.

• Vision problemscan impair the ability to see obstacles, judge depth and distance, or adjust to changes in light.Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.

• Home environmentcan pose safety hazards that can cause tripping, slipping, or losing balance.Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.

• Urinary incontinencecan lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls.Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.

Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults.However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.

Normal ranges for thyroid function tests vary depending on the laboratory and the method used.However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.

A. HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots. B. HRT can prevent osteoporosis, heart disease and dementia, but it can also cause weight gain, acne and hair loss. C. HRT can enhance sexual function, skin elasticity and memory, but it can also lower the immune system, blood pressure and blood sugar. D. HRT can improve sleep quality, energy levels and mood, but it can also worsen headaches, nausea and bloating.

Correct Answer is A

Explanation

The correct answer is A.

HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots.This answer is based on the evidence from various studies that have shown the benefits and risks of HRT.

Choice B is wrong because HRT cannot prevent osteoporosis, heart disease and dementia, and it does not cause weight gain, acne and hair loss.These are common misconceptions about HRT that are not supported by scientific research.

Choice C is wrong because HRT does not have a significant effect on sexual function, skin elasticity and memory, and it does not lower the immune system, blood pressure and blood sugar.These are also myths about HRT that have no basis in reality.

Choice D is wrong because HRT can improve sleep quality, energy levels and mood, but it can also cause or worsen headaches, nausea and bloating.These are some of the possible side effects of HRT that vary depending on the type, dose and duration of the therapy.

Normal ranges for estrogen and progesterone levels depend on the stage of menopause, the type of HRT and the individual factors of each woman.

Generally, estrogen levels range from 10 to 50 pg/mL (picograms per milliliter) and progesterone levels range from 0.1 to 25 ng/mL (nanograms per milliliter) in postmenopausal women.

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A nurse is assessing an older adult client who has a history of falls. Which of the following findings should the nurse identify as a risk factor for falls in older adults?

Nursing Test Bank

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Explanation

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A nurse is assessing an older adult client who has a history of falls.

Which of the following findings should the nurse identify as a risk factor for falls in older adults?