What expected physiological changes of the older adult put them at risk of falls? (Select all that apply).
Reduced muscle strength.
Sensory losses like vision and hearing.
Slowing of reflexes.
Dementia.
Inability to adapt.
Correct Answer : A,B,C
Reduced muscle strength, sensory losses like vision and hearing, and slowing of reflexes are all expected physiological changes of the older adult that can put them at risk of falls.
Reduced muscle strength can make it more difficult for older adults to maintain balance and stability.
Sensory losses like vision and hearing can affect an older adult’s ability to perceive their environment and navigate safely.
Slowing of reflexes can make it more difficult for older adults to react quickly to changes in their environment and prevent falls.
Choice D is not an answer because dementia is not a physiological change but rather a cognitive condition that can increase the risk of falls.
Choice E is not an answer because the inability to adapt is not a specific physiological change but rather a general characteristic that can increase the risk of falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
Correct Answer is B
Explanation
The client is experiencing neuropathic pain.
Pain after amputation can involve both nociceptive pain due to bone and soft tissue injury and neuropathic pain from direct neural trauma and central sensitization1.
This can lead to a complicated, mixed form of pain.
Choice A is not the correct answer because nociceptive pain is not the only type of pain that can occur after amputation.
Choice C is not the correct answer because cutaneous pain is not the type of pain being described.
Choice D is not the correct answer because visceral pain is not the type of pain being described.
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