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 A

Explanation

A. Ensuring ready access to a toilet or commode.

Explanation: Ensuring ready access to a toilet or commode for the client is a practical measure to address bowel incontinence. This proactive approach allows the client to respond to the urge to defecate promptly, reducing the risk of incontinence episodes.

B. Encouraging the intake of 1 L of water each day.

Explanation: While maintaining adequate hydration is important for overall bowel health, it may not directly address the issue of bowel incontinence.

C. Expecting a rapid and full recovery.

Explanation: The expectation of rapid and full recovery does not constitute a specific intervention for addressing bowel incontinence. The approach to managing bowel incontinence is typically individualized and may involve various strategies depending on the underlying causes.

D. Toileting the client 10 to 15 minutes after meals.

Explanation: Toileting the client after meals is a timing strategy that may help take advantage of the gastrocolic reflex, but it is only one aspect of a comprehensive program for managing bowel incontinence. Other interventions, such as dietary adjustments, exercise, and toileting schedules, may also be considered based on the client's specific needs.

A. The Global Deterioration Scale B. Mini Mental State Exam (MMSE) C. Older American's Resources and Services (OARS) D. Mini-Cog E. The Barthel Index

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

Explanation

A. The Global Deterioration Scale

Explanation: The Global Deterioration Scale (GDS) is a tool used to assess the cognitive function and stage of cognitive decline in individuals, especially those with dementia.

B. Mini Mental State Exam (MMSE)

Explanation: The Mini Mental State Exam (MMSE) is a widely used tool to assess cognitive function and screen for cognitive impairment. It evaluates various cognitive domains, including orientation, memory, attention, and language.

C. Older American's Resources and Services (OARS)

Explanation: The Older American's Resources and Services (OARS) is not a cognitive assessment tool. It is a comprehensive assessment tool that covers various domains, including physical health, mental health, and social resources.

D. Mini-Cog

Explanation: The Mini-Cog is a brief cognitive screening tool that includes a three-item recall test for memory and a clock-drawing task. It is used to quickly assess cognitive function and detect potential cognitive impairment.

E. The Barthel Index

Explanation: The Barthel Index is not a cognitive assessment tool. It is a tool used to assess an individual's ability to perform activities of daily living (ADLs), providing information about their functional independence rather than cognitive status.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which option is part of a program that addresses bowel incontinence in an older adult client?

Correct Answer is A

Explanation

The nurse assesses an older adult's cognitive status using a standard assessment instrument. Which of the following are cognitive assessment tools? (Select all that apply.)

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

Explanation

In assessing an older adult, you question his cognitive skills when you notice that

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