A nurse is caring for an older adult client in the emergency department who sustained a head injury due to a fall. Which of the following are common reasons for head injuries in older adults?
(Select All that Apply.)
Decreased visual acuity
Motor vehicle crashes
Polypharmacy
Weakness
Chronic hypertension
Previous military experience
Correct Answer : A,C,D,E
Choice A Reason:
Decreased visual acuity is correct. Yes, decreased visual acuity, including issues such as poor depth perception, reduced peripheral vision, and difficulty with contrast sensitivity, can contribute to falls and head injuries in older adults.
Choice B Reason:
Motor vehicle crashes is incorrect. While motor vehicle crashes can cause head injuries in individuals of all ages, they are less common among older adults compared to younger age groups.
Choice C Reason:
Polypharmacy is correct. Yes, polypharmacy, which refers to the use of multiple medications concurrently, is a common risk factor for falls and head injuries in older adults. Certain medications, especially those with sedative or psychotropic effects, can increase the risk of falls and accidents.
Choice D Reason:
Weakness is correct. Yes, weakness, frailty, and decreased muscle strength are common age-related changes that can increase the risk of falls and subsequent head injuries in older adults.
Choice E Reason:
Chronic hypertension, particularly when poorly controlled, can contribute to an increased risk of falls in older adults through various mechanisms:Hypertension medications or the condition itself can lead to orthostatic hypotension. This can cause dizziness or lightheadedness, increasing the risk of falls. Chronic hypertension is a major risk factor for cerebrovascular disease, including strokes. These events can lead to neurological deficits such as weakness, numbness, or impaired balance, predisposing individuals to falls.
Choice F Reason:
Previous military experience is incorrect. While previous military experience may contribute to certain health conditions or injuries in older adults, it is not a common reason for head injuries specifically related to falls or accidents in this population.
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Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client has no sensation or movement below the level of the injury is correct. This is a characteristic finding of a complete spinal cord injury, where there is total loss of sensory and motor function below the level of the injury. This pattern is often seen in injuries involving the cervical spinal cord, such as at the level of C7.
Choice B Reason:
The client has some movement but no sensation below the level of the injury is incorrect. This finding would be more indicative of an incomplete spinal cord injury, where there is partial preservation of sensory or motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained movement below the level of injury.
Choice C Reason:
The client has some movement and also some sensation below the level of the injury is incorrect. This finding is not typically associated with a spinal cord injury at the level of C7. With a transection of the spinal cord at this level, there is typically complete loss of sensory and motor function below the level of the injury.
Choice D Reason:
The client has some sensation but no movement below the level of the injury is incorrect. This finding is more consistent with an incomplete spinal cord injury, where there may be partial preservation of sensory function but no motor function below the level of the injury. However, with a transection of the spinal cord at C7, it is less likely for the client to have retained sensation below the level of injury.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
Choice B Reason:
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
Choice C Reason:
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
Choice D Reason
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
Choice E Reason:
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
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