During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Ask about the circumstances behind the fall(s).

Assess for any injuries the client might have.

Evaluate the client for gait and balance.

Ask about the history or frequency of falls.

Answer and Explanation

Correct Answer : A,D

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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Correct Answer is B

Explanation

Choice A reason: Measure the blood pressure in sitting and standing positions is not the next action by the nurse, as it is not relevant to the situation. The nurse should compare the blood pressure readings from both arms, not from different postures.

Choice B reason: Measure the blood pressure in the left arm is the next action by the nurse, as it can help determine if the high blood pressure is consistent or isolated to one arm. A difference of more than 10 mm Hg between the arms may indicate a vascular problem, such as atherosclerosis, aneurysm, or coarctation of the aorta.

Choice C reason: Document the findings in the medical record; elevated blood pressures are normal in older adults is not the next action by the nurse, as it is inaccurate and irresponsible. The nurse should not assume that elevated blood pressures are normal in older adults, as they may indicate hypertension, which is a risk factor for cardiovascular disease, stroke, and kidney damage. The nurse should also not document the findings without further assessment and intervention.

Choice D reason: Immediately contact the medical provider is not the next action by the nurse, as it may be premature and unnecessary. The nurse should first confirm the accuracy of the blood pressure readings by measuring the blood pressure in the left arm and checking the calibration of the device. The nurse should also consider other factors that may affect the blood pressure, such as pain, stress, caffeine, or medication.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the next action by the nurse.

A. Heart failure B. Functional impairments C. Longitudinal furrows on the tongue D. Hypertension E. Diabetes

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

Explanation

Choice A reason: Heart failure can cause fluid retention, which can lead to dehydration if the fluid is not properly balanced.

Choice B reason: Functional impairments can limit the ability to drink or access fluids, which can increase the risk of dehydration.

Choice C reason: Longitudinal furrows on the tongue are a sign of dehydration, as the tongue loses moisture and becomes dry and cracked.

Choice D reason: Hypertension is not directly related to dehydration, although it can be affected by fluid intake and electrolyte balance.

Choice E reason: Diabetes can cause increased urination, which can lead to dehydration if the fluid loss is not replaced.

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During an assessment, an older adult male client reports that he fell the night before. What should you follow up with? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse?

Correct Answer is B

Explanation

When assessing an older male client, what are some issues that might put him at risk for dehydration? (Select all that apply.)

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

Explanation

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