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

Increased sensitivity to touch.

Increase in cerumen in the ear canal.

Increased peripheral vision.

Increase in size of pupils.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.

Choice C rationale:

Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.

Choice D rationale:

An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.

Choice B rationale:

An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.

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Correct Answer is B

Explanation

Choice A rationale:

Increased collagen. Increased collagen is not a risk factor for pressure injuries. Collagen provides strength and support to the skin and tissues, which can be protective against pressure injuries by maintaining tissue integrity.

Choice B rationale:

Decreased circulation. Decreased circulation is a significant risk factor for pressure injuries. When blood flow to a specific area is reduced, it can lead to tissue ischemia, which makes the tissue more vulnerable to pressure damage. The lack of oxygen and nutrients from reduced circulation impairs the skin's ability to withstand pressure, increasing the risk of pressure injury development.

Choice C rationale:

Increased muscle mass. While having increased muscle mass can offer some protection against pressure injuries due to the added support and padding, it is not a primary risk factor for developing pressure injuries. In fact, individuals with increased muscle mass may be less prone to pressure injuries because their muscle tissue helps distribute pressure more evenly.

Choice D rationale:

Decreased serum calcium. Decreased serum calcium levels can affect muscle function and bone health but are not a direct risk factor for pressure injuries. Pressure injuries primarily result from sustained pressure on the skin and underlying tissues, often due to immobility and other factors. Calcium levels are not directly related to the development of pressure injuries.

A. Formal operational. B. Preoperational. C. Concrete operational. D. Sensorimotor.

Correct Answer is D

Explanation

Choice A rationale:

Piaget's formal operational stage is characterized by abstract thinking, hypothesis testing, and logical reasoning, but it does not include the development of object permanence. This stage typically occurs during adolescence, not in early childhood when object permanence is established.

Choice B rationale:

The preoperational stage is characterized by the development of symbolic thought and egocentrism but not object permanence. Object permanence starts to develop during the sensorimotor stage.

Choice C rationale:

Concrete operational thinking is focused on logical and systematic thinking related to concrete objects and events. It does not include the development of object permanence, which occurs in the earlier sensorimotor stage.

Choice D rationale:

Object permanence is a concept that develops during Piaget's sensorimotor stage, which typically occurs from birth to about two years of age. During this stage, children learn that objects continue to exist even when they are out of sight. They develop the ability to represent objects mentally and understand the concept of permanence.

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

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