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

Hearing

Vision

Cognitive disorders

Preprandial hypotension

Orthostatic hypotension

Answer and Explanation

Correct Answer : B,C,D,E

A. Hearing.

While hearing impairment can affect overall awareness, it is not as directly linked to the risk of falls as vision, cognitive disorders, and blood pressure-related issues.

B. Vision.

Correct. Visual impairment can contribute to an increased risk of falls.

C. Cognitive disorders.

Correct. Cognitive impairment or disorders can impact a person's awareness and ability to navigate their environment safely.

D. Preprandial hypotension.

Correct. Low blood pressure before meals (preprandial hypotension) can contribute to dizziness and falls, especially in older adults.

E. Orthostatic hypotension.

Correct. Orthostatic hypotension, a drop in blood pressure upon standing, is a risk factor for falls.

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Correct Answer is B

Explanation

A. Encouraging the client to use a cane when ambulating.

Explanation: Encouraging the use of a cane for ambulation can provide support and stability, aiding in fall prevention.

B. Keeping the side rails up on the client's bed at night.

Explanation: Keeping side rails up on the client's bed can pose a concern as it may increase the risk of entrapment and injury. Side rails can lead to accidental entrapment, and there is a potential for the client to try to climb over them, leading to falls or injuries. The use of side rails in older adults is a safety consideration that requires careful assessment and appropriate measures to prevent harm.

C. Keeping several low wattage night lights on in the evening.

Explanation: Using low wattage night lights is a good practice to enhance visibility and prevent tripping or stumbling in low-light conditions.

D. Installing wooden railings on the stairway to the bathroom.

Explanation: Installing railings on the stairway is a proactive measure to enhance safety and stability, especially in navigating stairs, and can contribute to fall prevention.

A. Use cool or tepid water. B. Avoid alcohol. C. Minimize exertion D. Wear cool clothing such as silk on polyester E. Drink plenty of fluids

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Use cool or tepid water: Applying cool or tepid water to the body, such as through a cool bath or damp cloth, can help reduce body temperature.

B. Avoid alcohol: Alcohol can contribute to dehydration, which increases the risk of hyperthermia. It's important to encourage the client to avoid alcoholic beverages during hot weather.

C. Minimize exertion: Exertion in high temperatures can lead to an increase in body heat. Advising the elderly client to minimize physical exertion during hot weather helps prevent overheating.

D. Wear cool clothing such as silk or polyester: Light and breathable fabrics, such as silk or polyester, promote better air circulation and help the body stay cool.

E. Drink plenty of fluids: Staying hydrated is crucial in preventing hyperthermia. Encourage the client to drink plenty of fluids, particularly water, to maintain proper hydration levels.

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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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Naxlex Comprehensive Predictor Exams

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

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

The overall temperature in the gerontological unit is 62°F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

Components to a cognitive assessment include which of the following? (Select all that apply.)

Which is the fundamental difference between Medicare Part A and Medicare Part B?

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?

The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)