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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The conservator will function in the same capacity as a health care proxy.
Explanation: A conservator and a health care proxy serve different roles. A conservator is appointed by a court to manage financial affairs, while a health care proxy is designated to make medical decisions on behalf of the individual if they are unable to do so. These roles are not interchangeable.
B. This client does not have the capacity to give informed consent for any procedures.
Explanation: The presence of a conservator alone does not automatically indicate a lack of capacity to give informed consent. Capacity for making healthcare decisions is determined on an individual basis and may vary depending on the client's cognitive and decision-making abilities.
C. The presence of a conservator does not mean the client cannot give informed consent.
Explanation: Having a court-appointed conservator to manage finances does not automatically imply that the client lacks the capacity to provide informed consent for medical procedures. The ability to make healthcare decisions, including giving informed consent, is distinct from financial capacity. Even if a conservator is appointed for financial matters, the client may still have the capacity to participate in decisions related to their health and medical treatment.
D. The nurse needs to provide all educational materials to the conservator instead of the client.
Explanation: Educational materials related to the client's healthcare should be provided directly to the client whenever possible. While the conservator may be involved in financial matters, the client should still receive relevant information regarding their health and medical care.
Correct Answer is B
Explanation
A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.
B. Providing information on group exercises for balance training is a suitable intervention.
Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.
Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.
C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.
D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.
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