When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

stiffening of the large arteries

rise in the systolic blood pressure

postural orthostatic hypotension

Decline of pacemaker cells in the sino-atrial node

Answer and Explanation

The Correct Answer is C

A. Stiffening of the large arteries: Stiffening of the large arteries is a common age-related change and can contribute to increased systolic blood pressure. While this change can affect cardiovascular function, it does not directly increase the risk of falls as much as other factors.
B. Rise in the systolic blood pressure: An increase in systolic blood pressure often occurs with aging due to arterial stiffening. Elevated systolic blood pressure alone does not directly cause an increased risk of falls but is a part of the broader spectrum of cardiovascular changes.
C. Postural orthostatic hypotension: Postural orthostatic hypotension (OH) is characterized by a significant drop in blood pressure when a person stands up from a sitting or lying position, leading to dizziness or lightheadedness. This condition is common in older adults and significantly increases the risk of falls, as it can cause sudden dizziness and unsteadiness upon standing.
D. Decline of pacemaker cells in the sino-atrial node: The decline of pacemaker cells in the sinoatrial node can lead to bradycardia or irregular heart rhythms, which are related to cardiac function. While this can affect overall cardiovascular health, it does not directly contribute to the risk of falls as much as the sudden changes in blood pressure associated with postural orthostatic hypotension.

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Correct Answer is D

Explanation

A. Flatness: This percussion note is typically associated with areas of high density, such as over muscle or a solid organ like the liver. In a pneumothorax, the lung tissue is not solidified, so flatness is not expected.
B. Dullness: Dullness is generally noted over fluid-filled areas or solid structures, such as a pleural effusion or a mass. In the case of a pneumothorax, where there is air in the pleural space, dullness would not be the expected finding.
C. Resonance: Resonance is the normal percussion note over healthy lung tissue. It indicates normal air-filled lung spaces. In a pneumothorax, the increased air in the pleural space causes an abnormal note.
D. Hyperresonance: This percussion note is associated with increased air in the pleural space, as seen in conditions like a pneumothorax. The extra air causes a more resonant, hollow sound when percussed, distinguishing it from normal lung resonance.

A. Implement an intervention. B. Perform an assessment C. Develop a nursing diagnosis. D. Evaluate an outcome.

Correct Answer is D

Explanation

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

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When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is diagnosed with a Pneumothorax on the right lung. During the assessment, when percussing this area the nurse expects to find the percussion note as:

Correct Answer is D

Explanation

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Correct Answer is D

Explanation

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