A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?

Unsteady gait

Report of short-term memory loss

Hearing loss

Report of frequent constipation

Answer and Explanation

The Correct Answer is A

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B.   Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C.   Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D.   Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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Correct Answer is C

Explanation

A. 1+ pitting edema is mild, with a slight indentation.

B. 4+ pitting edema is severe, with a deep indentation that lasts a long time.

C. 3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.

A. Decreased hematocrit B. Decreased specific gravity of urine C. Increased skin turgor D. Increased pulse rate

Correct Answer is D

Explanation

A. Decreased hematocrit may be seen in fluid volume excess, not deficit.

B. Decreased specific gravity of urine is more indicative of dilution rather than fluid volume deficit.
C. Increased skin turgor is a clinical manifestation of fluid volume deficit.

D. Increased pulse rate is a compensatory response to fluid volume deficit, reflecting the body's attempt to maintain perfusion in the setting of reduced blood volume.

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A nurse is performing an assessment of an older adult client in an assisted living facility. Which of the following findings is the highest priority for the nurse to address when planning care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?