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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer isD.
All of the above.
The nurse should take all of the actions listed to provide effective pain management for the older adult client who has depression and chronic pain in his lower back.
• Choice Ais correct because assessing the pain using a valid and reliable pain scale is essential for determining the severity and impact of pain, as well as monitoring the response to treatment.
• Choice Bis correct because administering analgesic medications as prescribed can help reduce pain and improve function.
The nurse should also monitor for effectiveness and side effects, especially in older adults who may have altered drug metabolism, polypharmacy, and increased risk of adverse events.
• Choice Cis correct because providing non-pharmacological interventions can enhance pain relief, reduce medication use, and address the biopsychosocial aspects of pain.
Massage, heat or cold therapy, relaxation techniques, and distraction are some examples of non-pharmacological interventions that can be used for chronic pain in older adults.
• Choice Dis correct because it includes all of the above actions, which are part of a multimodal approach to pain management that is recommended by clinical guidelines.
4 7 A multimodal approach can improve pain outcomes, reduce side effects, and address the complex needs of older adults with chronic pain.
A. Assess the location, intensity, quality and duration of the pain using a pain scale B.
Administer analgesic medications as prescribed and monitor for effectiveness and side effects C.
Provide non-pharmacological interventions such as massage, heat or cold therapy, relaxation techniques or distraction D.
All of the above
Correct Answer is ["A","B","E"]
Explanation
The correct answer isA, B, and E.
The nurse should instruct the patient to do the following:.
• Trim nails straight across and file edges smoothly.
• Soak nails in warm water before trimming to soften them.
• Report any signs of infection or inflammation around nails.
These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.
Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.
To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.
:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.
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