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?

The correct answer is D.

Delirium.

The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.

Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.

Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.

Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.

Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.

Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.

Choice C is wrong because seizures are not a common complication of fever in older adults.

Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.

Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.

Fever-induced seizures are more likely to occur in young children than in older adults.

The correct answer is D.

All of the above.

This is because all of these findings indicate that the client has experienced an improvement in mood, energy, appetite, sleep, interest and participation in social activities and hobbies, which are common signs of depression recovery.

Choice A is wrong because it only covers some of the symptoms of depression, such as mood, energy, appetite and sleep, but not others, such as interest and participation in social activities and hobbies.

Choice B is wrong because it only measures the client’s depression level using standardized scales, such as the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9), but not their actual functioning and quality of life.

Choice C is wrong because it only reflects the client’s interest and participation in social activities and hobbies, which are important aspects of depression recovery, but not their mood, energy, appetite, sleep or depression level.

The GDS and the PHQ-9 are both valid and reliable tools for screening and measuring depression in older adults.

The GDS is a 15-item questionnaire that asks the client to answer yes or no to questions about their mood, satisfaction, hopelessness, helplessness, worthlessness, guilt, agitation, withdrawal and suicidal thoughts.

The PHQ-9 is a 9-item questionnaire that asks the client to rate how often they have experienced symptoms of depression in the past two weeks, such as depressed mood, anhedonia, insomnia or hypersomnia, fatigue, appetite or weight changes, concentration problems, feelings of worthlessness or guilt.

A. The client reports an improvement in mood, energy, appetite and sleep B.

The client scores lower on the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9) C.

The client shows more interest and participation in social activities and hobbies D.

All of the above