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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
The correct answer isA, B, C, D, and E.
All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work.A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery.The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.
• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.
• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.
• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.
• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.
• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.
A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people.The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health.Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.
Correct Answer is ["A","B","C","D"]
Explanation
These interventions are appropriate for reducing social isolation in older adult clients who live in a long-term care facility because they provide opportunities for social interaction, support, comfort and familiarity.
Choice A is correct because group activities such as games, music, art or exercise can foster a sense of belonging, enjoyment and engagement among older adults.Group activities can also improve physical and mental health, cognitive function and well-being.
Choice B is correct because encouraging family members or volunteers to visit or call the clients regularly can enhance the quality and quantity of social relationships, which can reduce loneliness and isolation.Family members or volunteers can also provide emotional support, companionship and practical assistance to the clients.
Choice C is correct because creating a homelike environment that promotes comfort, safety and privacy can increase the clients’ satisfaction, autonomy and dignity.A homelike environment can also facilitate social interactions among the clients and the staff by providing common areas, personal belongings and familiar objects.
Choice D is correct because assigning consistent staff members who are familiar with the clients’ needs and preferences can improve the continuity and quality of care, as well as the trust and rapport between the clients and the staff.Consistent staff members can also recognize and respond to the clients’ social needs and preferences, and provide personalized interventions.
Choice E is incorrect because providing feedback or recognition for the clients’ achievements or contributions may not be effective in reducing social isolation, unless it is combined with other interventions that promote social interaction and support.Feedback or recognition alone may not address the underlying causes of social isolation, such as lack of meaningful relationships, low self-esteem or poor health.
Normal ranges for social isolation and loneliness are difficult to define, as they depend on various factors such as individual characteristics, cultural norms and measurement tools.However, some indicators of social isolation include having few or no social contacts, participating in few or no social activities, feeling disconnected from others or society, and having low levels of perceived social support.Some indicators of loneliness include feeling unhappy about one’s social situation, feeling left out or unwanted, lacking companionship or intimacy, and having low levels of perceived belongingness or connectedness.
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