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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
You can do any of the above options, depending on your preference and medical condition.
Erectile dysfunction (ED) is the inability to get and maintain an erection for sexual activity.
It can be caused by physical or psychological factors, or both.
ED can affect your self-esteem, stress level and relationship quality.
There are different treatment options for ED, and they work in different ways.
Some of the most common ones are:.
• Oral medicationssuch as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Stendra).
These drugs enhance the effects of nitric oxide, a chemical that relaxes the muscles in the penis and increases blood flow.
You need to take them before sexual activity, and they only work if you are sexually stimulated.
They are not safe for everyone, especially if you have heart problems, low blood pressure, liver disease or certain eye conditions.They can also cause side effects such as headache, flushing, nasal congestion or indigestion.
• Penile self-injectionssuch as alprostadil (Caverject, Edex) or papaverine (OraVerse).
These are shots of medicine that you inject into the base or side of your penis with a fine needle.
They cause an erection by dilating the blood vessels in the penis.
The erection lasts about 20 to 30 minutes, and you need to use them only when needed.They can cause side effects such as bleeding, pain, priapism (a prolonged and painful erection) or fibrous tissue formation.
• Alprostadil urethral suppository(Muse).
This is a tiny pellet of medicine that you insert into your urethra (the tube that carries urine out of the body) with a special device.
It works by expanding the blood vessels in the penis and causing an erection.
The erection lasts about 30 to 60 minutes, and you need to use it only when needed.It can cause side effects such as burning, pain, bleeding or infection.
• Vacuum erection device(VED).
This is a plastic tube that you place over your penis and pump out the air to create a vacuum.
This draws blood into the penis and causes an erection.
You then slide a rubber ring around the base of your penis to keep the blood in place.
The erection lasts as long as the ring is on, up to 30 minutes.
You need to use it only when needed.It can cause side effects such as bruising, numbness, pain or difficulty ejaculating.
• Penile implant surgery.
This is a procedure where inflatable or bendable devices are surgically placed on both sides of your penis.
You can control when and how long you have an erection by inflating or deflating the devices with a pump or a switch.This is a permanent solution for ED, but it requires surgery and has risks of infection, mechanical failure or erosion.
Other treatment options for ED include hormone therapy, psychotherapy, lifestyle changes and natural remedies.
However, these may not be as effective or safe as the ones mentioned above.
The best treatment option for you depends on your personal preference, medical condition, cost and availability.
You should talk to your doctor about the benefits and risks of each option and choose the one that suits you best.
Correct Answer is C
Explanation
The correct answer is C.
Check for bladder distention or fecal impaction.
Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.
It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.
Bladder or bowel distension are the most common triggers of autonomic dysreflexia.
Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.
This can help to eliminate the stimulus and lower the blood pressure.
Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.
The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.
Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.
Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.
Normal ranges for blood pressure vary depending on age, sex, and other factors.
However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.
Normal ranges for heart rate also vary depending on age, activity level, and other factors.
However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.
References:.
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