The nurse is assessing an older adult client who has osteoporosis and reports frequent falls.

The nurse should ask the client about which of the following factors that could contribute to falls?

(Select all that apply.).

Medications

Vision problems

Home environment.

Thyroid function.

Urinary incontinence.

Answer and Explanation

Correct Answer : A,B,C,E

The correct answer is A, 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.

• Medications can 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 problems can 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 environment can 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 incontinence can 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.

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Correct Answer is A

Explanation

The correct answer is A.

Decreased metabolic rate.This is because the metabolic rate is the amount of energy that the body uses to maintain its functions, and it tends to decline with age due to various factors, such as loss of muscle mass, reduced activity, hormonal changes, and decreased thyroid function.

A lower metabolic rate means that the body produces less heat and therefore feels colder more easily.

Choice B is wrong because increased blood pressure is not a normal physiological change with aging, but rather a risk factor for cardiovascular diseases that can be influenced by lifestyle, genetics, and other factors.

Choice C is wrong because increased sweat gland activity is not a normal physiological change with aging, but rather a sign of hyperhidrosis, which is a condition that causes excessive sweating due to overactive sweat glands.Sweat glands actually decrease in number and function with age, which can impair thermoregulation and increase the risk of heat-related illnesses.

Choice D is wrong because decreased body fat is not a normal physiological change with aging, but rather a result of malnutrition, illness, or other causes.Body fat actually tends to increase with age, especially in the abdominal region, due to hormonal changes, reduced physical activity, and lower metabolic rate.

Body fat can act as an insulator and help maintain body temperature.

Normal ranges for metabolic rate vary depending on age, sex, body size, activity level, and other factors.

A general estimate for resting metabolic rate (RMR) is 10 calories per kilogram of body weight per day for men and 9 calories per kilogram of body weight per day for women.

However, this may not reflect the actual metabolic rate of an individual, as it does not account for the effects of food intake, exercise, or environmental factors.

Therefore, it is better to measure metabolic rate using indirect calorimetry or other methods that can capture these variables.

A. Dehydration B. Hypothermia C. Seizures D. Delirium

Correct Answer is D

Explanation

The correct answer is D.

Delirium.

The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.

Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.

Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.

Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.

Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.

Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.

Choice C is wrong because seizures are not a common complication of fever in older adults.

Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.

Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.

Fever-induced seizures are more likely to occur in young children than in older adults.

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The nurse is assessing an older adult client who has osteoporosis and reports frequent falls. The nurse should ask the client about which of the following factors that could contribute to falls? (Select all that apply.).

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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The nurse is assessing an older adult client who has osteoporosis and reports frequent falls.

The nurse should ask the client about which of the following factors that could contribute to falls?

(Select all that apply.).