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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.

Answer and Explanation

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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Correct Answer is ["A","B","C","E"]

Explanation

The correct answer isA, B, C, and E.

The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.

• Medicationscan increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure.Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.

• Vision problemscan impair the ability to see obstacles, judge depth and distance, or adjust to changes in light.Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.

• Home environmentcan pose safety hazards that can cause tripping, slipping, or losing balance.Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.

• Urinary incontinencecan lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls.Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.

Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults.However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.

Normal ranges for thyroid function tests vary depending on the laboratory and the method used.However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.

A. Decreased immune response B. Decreased chest wall compliance C. Decreased alveolar surface area. D. Decreased oxygen saturation. E. Decreased bronchial dilation.

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

Explanation

The correct answer is A, B and C.

These are the factors that increase the risk of respiratory infections in elderly patients:.

• Decreased immune response: Elderly patients have a weaker immune system that makes them more susceptible to viral and bacterial infections.They also have a poor response to respiratory vaccines.

• Decreased chest wall compliance: Elderly patients have reduced elasticity of the lungs and chest wall, which makes it harder for them to breathe and expel mucus.

• Decreased alveolar surface area: Elderly patients have fewer and larger alveoli, which reduces the gas exchange area and oxygen diffusion capacity.

Choice D is wrong because decreased oxygen saturation is not a risk factor, but a consequence of respiratory infections.

Choice E is wrong because decreased bronchial dilation is not a specific factor for elderly patients, but a common feature of obstructive lung diseases.

Normal ranges for oxygen saturation are 95-100% and for bronchial dilation are variable depending on the type and severity of the disease.

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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.).

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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.).