The nurse is caring for an elderly patient who has been admitted with pneumonia.
The nurse knows that elderly patients are at increased risk for respiratory infections because of which of the following factors?
(Select all that apply.).
Decreased immune response
Decreased chest wall compliance
Decreased alveolar surface area.
Decreased oxygen saturation.
Decreased bronchial dilation.
Correct Answer : A,B,C
The correct answer is A, B and C.
These are the factors that increase the risk of respiratory infections in elderly patients:.
• Decreased immune response: Elderly patients have a weaker immune system that makes them more susceptible to viral and bacterial infections. They also have a poor response to respiratory vaccines.
• Decreased chest wall compliance: Elderly patients have reduced elasticity of the lungs and chest wall, which makes it harder for them to breathe and expel mucus.
• Decreased alveolar surface area: Elderly patients have fewer and larger alveoli, which reduces the gas exchange area and oxygen diffusion capacity.
Choice D is wrong because decreased oxygen saturation is not a risk factor, but a consequence of respiratory infections.
Choice E is wrong because decreased bronchial dilation is not a specific factor for elderly patients, but a common feature of obstructive lung diseases.
Normal ranges for oxygen saturation are 95-100% and for bronchial dilation are variable depending on the type and severity of the disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
Correct Answer is ["A","B","C"]
Explanation
The correct answer isA, B, and C.
These interventions are appropriate for a client who has impaired tactile sensation due to aging.
• Ais 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.
• Bis 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.
• Cis 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.
• Dis 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.
• Eis 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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