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 D

Explanation

A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.

C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.

D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

A. Date of birth B. Diagnosis C. Identification number D. Name E. Room Number

Correct Answer is ["A","C","D"]

Explanation

A. Date of birth is a commonly used identifier to confirm the client's identity.

B. Diagnosis is not an appropriate identifiers for confirming a client's identity.

C. Identification number is a unique identifier assigned to each client, helping ensure accurate identification.
D. Name is a fundamental identifier and should be used in combination with other identifiers to verify the client's identity.
E. Room number is not an appropriate identifiers for confirming a client's identity.

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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?

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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?