An older adult who is a non-Hispanic Caucasian has a fasting blood sugar level above 130 mg/dL. Which client assessment does the nurse use to confirm a high risk for diabetes mellitus in the client?
120/80 mm Hg
Total cholesterol 198 mg/dL
Palpable peripheral pulses
68 years of age
The Correct Answer is D
Choice A reason: This is incorrect because 120/80 mm Hg is a normal blood pressure, not a high risk factor for diabetes mellitus. High blood pressure, or hypertension, is a common complication of diabetes mellitus, as it can damage the blood vessels and increase the risk of cardiovascular disease. However, having a normal blood pressure does not rule out the possibility of having diabetes mellitus, as other factors, such as blood sugar level, family history, or lifestyle, can also influence the risk.
Choice B reason: This is incorrect because total cholesterol 198 mg/dL is a borderline high cholesterol level, not a high risk factor for diabetes mellitus. High cholesterol, or hyperlipidemia, is a common complication of diabetes mellitus, as it can affect the metabolism of fats and increase the risk of atherosclerosis and cardiovascular disease. However, having a borderline high cholesterol level does not confirm the diagnosis of diabetes mellitus, as other factors, such as blood sugar level, family history, or lifestyle, can also influence the risk.
Choice C reason: This is incorrect because palpable peripheral pulses are a normal finding, not a high risk factor for diabetes mellitus. Peripheral pulses are the pulsations of the arteries that can be felt in the extremities, such as the wrists or ankles. Palpable peripheral pulses indicate that the blood flow to the extremities is adequate and not compromised by diabetes mellitus. However, having palpable peripheral pulses does not rule out the possibility of having diabetes mellitus, as other factors, such as blood sugar level, family history, or lifestyle, can also influence the risk.
Choice D reason: This is correct because 68 years of age is a high risk factor for diabetes mellitus. Age is one of the non-modifiable risk factors for diabetes mellitus, as the risk increases with advancing age. This is because aging can affect the insulin production and sensitivity, as well as the body composition and function. Older adults are more likely to have diabetes mellitus than younger adults, especially if they have other risk factors, such as obesity, family history, or sedentary lifestyle. Therefore, 68 years of age is a high risk factor for diabetes mellitus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: 2400 mL/day is the recommended fluid intake for older adults, according to the National Council on Aging. This amount can help prevent dehydration, which can cause various health problems in older adults, such as urinary tract infections, constipation, confusion, and falls.
Choice B reason: 1920 mL/day is not enough fluid intake for older adults, as it is below the minimum requirement of 6-8 glasses of fluid a day, according to Age UK. This amount can increase the risk of dehydration and its complications in older adults.
Choice C reason: 3000 mL/day is too much fluid intake for older adults, as it exceeds the maximum limit of 10 glasses of fluid a day, according to The Conversation. This amount can cause overhydration, which can lead to hyponatremia, a condition where the sodium level in the blood becomes too low. Hyponatremia can cause symptoms such as nausea, headache, confusion, and seizures.
Choice D reason: 1500 mL/day is not enough fluid intake for older adults, as it is half of the recommended amount of 2400 mL/day, according to the National Council on Aging. This amount can increase the risk of dehydration and its complications in older adults.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Asking about the circumstances behind the fall(s) can help you identify the possible risk factors and causes of the fall(s), such as environmental hazards, medications, chronic conditions, or acute illnesses. Asking about the circumstances can also help you determine the severity and urgency of the situation, and whether the client needs further evaluation or referral.
Choice B reason: Assessing for any injuries the client might have is important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any life-threatening or serious injuries that may require immediate attention. Assessing for injuries is part of the comprehensive fall risk assessment that should be done after the initial screening.
Choice C reason: Evaluating the client for gait and balance is also important, but it is not the first thing you should do after a client reports a fall. You should first ask about the circumstances to rule out any underlying medical conditions that may affect the client's gait and balance. Evaluating gait and balance is part of the comprehensive fall risk assessment that should be done after the initial screening.
Choice D reason: Asking about the history or frequency of falls can help you assess the client's fall risk and identify any patterns or trends in the client's fall history. Asking about the history or frequency of falls can also help you tailor the appropriate interventions and prevention strategies for the client.
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