A nurse is planning care for an older adult client who has impaired tactile sensation due to aging.
Which of the following interventions should the nurse include?
(Select all that apply.).
Monitor the client’s skin for signs of injury or infection.
Teach the client to avoid exposure to extreme temperatures.
Encourage the client to use assistive devices for mobility and balance.
Provide the client with sensory stimulation such as massage or music.
Advise the client to wear loose-fitting clothing and shoes.
Correct Answer : A,B,C
The correct answer is A, B, and C.
These interventions are appropriate for a client who has impaired tactile sensation due to aging.
• A is correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.
• B is correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.
• C is correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.
• D is wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging. While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.
• E is wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging. In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.
Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.
However, some general guidelines are:.
• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.
• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.
• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.
• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.
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Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Living arrangements and social support.
This is because living arrangements and social support are some of the environmental factors that can influence the psychosocial changes in older adults.Psychosocial changes refer to the changes in mental and emotional well-being, social relationships, and roles that occur as people age.Environmental factors are the external conditions or circumstances that affect a person’s life.
Choice A is wrong because physical health and functional status are not environmental factors, but rather biological factors that affect the aging process.Physical health and functional status can influence the psychosocial changes in older adults, but they are not part of the environment.
Choice B is wrong because cognitive conditions and memory loss are also not environmental factors, but rather neurological factors that affect the brain function of older adults.Cognitive conditions and memory loss can also influence the psychosocial changes in older adults, but they are not part of the environment.
Choice D is wrong because hormonal changes and sensory impairments are also not environmental factors, but rather physiological factors that affect the body function of older adults.Hormonal changes and sensory impairments can also influence the psychosocial changes in older adults, but they are not part of the environment.
Living arrangements and social support are environmental factors because they depend on the availability, accessibility, and quality of housing, transportation, community services, family networks, and social interactions that older adults have in their surroundings.Living arrangements and social support can influence the psychosocial changes in older adults by affecting their sense of independence, identity, belonging, security, and satisfaction.
Therefore, living arrangements and social support are some of the environmental factors that can influence the psychosocial changes in older adults.
Correct Answer is D
Explanation
The correct answer is D.
Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
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