The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Use of resistance bands

Stretching

Tat chi

Yoga

ROM activities

Answer and Explanation

Correct Answer : C,D,E

A. Use of resistance bands
Explanation: Resistance band exercises can improve strength and flexibility, but they may not specifically address balance as directly as Tai Chi or certain yoga poses.

B. Stretching
Explanation: Stretching exercises contribute to flexibility and can be part of a well-rounded exercise routine. While they can be beneficial, other exercises like Tai Chi and yoga may have a more specific focus on balance improvement.

C. Tai Chi
Explanation: Tai Chi is a low-impact exercise that emphasizes slow, controlled movements, weight shifting, and mindfulness. It has been shown to improve balance and reduce the risk of falls, making it suitable for individuals at high risk.

D. Yoga
Explanation: Yoga incorporates balance, flexibility, and strength exercises. Certain yoga poses can help improve balance and stability, making it beneficial for individuals at risk for falls.

E. Range of Motion (ROM) activities
Explanation: Range of motion activities helps maintain joint flexibility and can contribute to improved balance. Encouraging the client to perform gentle range of motion exercises can be beneficial.

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Correct Answer is B

Explanation

A. Age-related motor deficiencies that result in self-neglect.

Explanation: While age-related motor deficiencies could potentially impact a person's ability to dress appropriately, the specific scenario described (wearing a sweater despite high temperatures) is more indicative of sensory awareness issues rather than motor deficiencies.

B. Age-related neurosensory changes that diminish awareness of temperature changes.

Explanation: As individuals age, there can be neurosensory changes that affect their ability to perceive temperature accurately. This can result in older adults being less aware of changes in temperature, leading to behaviors such as dressing inappropriately for the weather. In this scenario, the client wearing a sweater despite the high temperature outside may be attributed to diminished awareness of the actual environmental temperature.

C. Delirium related to an acute illness that is affecting body heat production.

Explanation: Delirium may indeed affect a person's cognitive and functional abilities, but the scenario does not provide evidence of delirium or an acute illness. The focus is on the client's behavior related to dressing inappropriately for the weather, which is more suggestive of sensory awareness issues.

D. Cognitive changes that diminish the individual's awareness of temperature changes.

Explanation: This option is similar to the correct answer (Option B). Cognitive changes, particularly in awareness, can contribute to inappropriate dressing for the weather in older adults. The primary distinction here is that the term "neurosensory changes" in Option B specifically highlights alterations in sensory perception.

A. Decreased serum albumin levels B. Decreased vitamin D levels C. Unintentional weight loss, D. Anorexia lasting more than 24 hours

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.

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The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90°F outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to what?

Correct Answer is B

Explanation

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

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Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

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When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

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