The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Balance

Stride

Flexibility

Speed

Answer and Explanation

The Correct Answer is A

A. Balance:

The Get-Up-and-Go test assesses the patient's ability to maintain balance during the process of standing up from a chair, walking a short distance, turning around, and sitting down. Impaired balance can be a significant risk factor for falls.

B. Stride:

Stride, or the length of a person's step, is not explicitly assessed in the Get-Up-and-Go test. However, the test may indirectly provide information about the patient's walking pattern and step characteristics.

C. Flexibility:

While flexibility is not a specific focus of the Get-Up-and-Go test, the test involves movements that require a degree of joint flexibility, such as bending the knees to stand up and sit down.

D. Speed:

Speed is an important aspect of the Get-Up-and-Go test. The time taken by the patient to complete the entire sequence of standing up, walking, turning, and sitting down is considered. Slower performance on the test may indicate an increased risk of falls.

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Correct Answer is C

Explanation

A. Decreased serum albumin levels can be an indicator of protein malnutrition, but it may not reflect overall nutritional status comprehensively. It is more specific to protein status.

B. Decreased vitamin D levels are related to a specific nutrient (vitamin D) and may indicate a deficiency in that vitamin, but it doesn't provide a broad assessment of overall nutritional status.

C. Unintentional weight loss is a key indicator of potential nutritional deficit.

Unintentional weight loss is a significant concern, especially in older adults, as it can be indicative of various underlying health issues, including malnutrition. It is a more general indicator of overall nutritional status.

D. Anorexia lasting more than 24 hours may contribute to weight loss, but it is a symptom rather than a direct measure of nutritional status. Unintentional weight loss encompasses a broader view of changes in body weight that may signal nutritional deficits.

A. Two servings of deep-colored fruit B. Six or more servings of fortified, enriched, or whole grain foods C. Three or more servings of low-fat or nonfat dairy products D. Three 8 ounce glasses of water E. Four or more servings of high quality protein F. One or two servings of brightly colored vegetables

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

Explanation

A. Two servings of deep-colored fruit.

While fruits are recommended, the "deep-colored" specification is not a specific focus in the MyPlate for Older Adults.

B. Six or more servings of fortified, enriched, or whole grain foods.

Correct. Whole grains are an important source of fiber, vitamins, and minerals.

C. Three or more servings of low-fat or nonfat dairy products.

Correct. Dairy products provide calcium and vitamin D, important for bone health.

D. Three 8-ounce glasses of water.

Correct. Staying hydrated is crucial for overall health, especially for older adults.

E. Four or more servings of high-quality protein.

Correct. Protein is essential for muscle maintenance and repair. Sources of high-quality protein include lean meats, poultry, fish, eggs, dairy, and plant-based protein sources.

F. One or two servings of brightly colored vegetables.

While vegetables are recommended, the "brightly colored" specification is not a specific focus in the MyPlate for Older Adults.

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The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

Correct Answer is C

Explanation

Which recommendations for daily food intake is correct for older adults according to the MyPlate for Older Adults? (Select all that apply.)

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

Explanation

In assessing an older adult, you question his cognitive skills when you notice that

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