Which of the following assessment(s) is/are considered reliable in the older adult? (Select all that apply.)
Skin turgor at the sternum
Orthostasis
Sunken eyes
Decreased urine output
Correct Answer : A,B
Choice A reason: This assessment is reliable in the older adult because the skin turgor at the sternum is less affected by age-related changes in skin elasticity and hydration than other sites, such as the forearm or the hand. The skin turgor at the sternum can indicate the fluid status of the older adult, as well as the presence of dehydration or edema.
Choice B reason: This assessment is reliable in the older adult because orthostasis, or a drop in blood pressure when changing positions, is a common condition in this population. Orthostasis can be caused by various factors, such as medications, dehydration, anemia, or autonomic dysfunction. Orthostasis can increase the risk of falls, dizziness, syncope, or cardiovascular complications in the older adult.
Choice C reason: This assessment is not reliable in the older adult because sunken eyes are not a specific sign of dehydration in this population. Sunken eyes can be a normal age-related change in the facial structure, or a result of other factors, such as weight loss, malnutrition, or chronic illness. Sunken eyes can also be influenced by the lighting, the angle of observation, or the presence of glasses or contact lenses.
Choice D reason: This assessment is not reliable in the older adult because decreased urine output is not a sensitive indicator of dehydration in this population. Decreased urine output can be influenced by various factors, such as renal function, fluid intake, medications, or environmental conditions. Decreased urine output can also be a sign of other conditions, such as urinary tract infection, urinary retention, or renal failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Regular exercise should exceed 30 minutes three times a week, not not exceed. Exercise helps lower blood glucose levels and improve insulin sensitivity.
Choice B reason: A walking program is recommended for an older adult with diabetes, not not recommended. Walking is a low-impact, moderate-intensity exercise that can benefit people with diabetes.
Choice C reason: Insulin can not be discontinued if the individual adheres to the walking program, not most probably. Insulin is a vital hormone that regulates blood glucose levels and prevents complications from diabetes. Exercise alone is not enough to replace insulin therapy.
Choice D reason: The walking regimen needs to be done on a regularly scheduled basis. This is the correct answer because it helps the individual maintain a consistent blood glucose level and avoid hypoglycemia or hyperglycemia. It also helps the individual plan their insulin doses and meals accordingly.
Correct Answer is A
Explanation
Choice A reason: Crushing chest pain is the classic sign of an AMI, but it can be absent in some older men with an AMI. This is because older men may have a reduced pain perception due to aging, diabetes, or other conditions that affect the nerve endings. Older men may also have atypical or silent AMIs, which do not cause chest pain or other obvious symptoms.
Choice B reason: Epigastric burning is not a classic sign of an AMI, but it can be a symptom of an AMI in some older men. Epigastric burning may be mistaken for indigestion, heartburn, or gastritis, but it can also indicate ischemia or injury to the lower part of the heart.
Choice C reason: Dyspnea and fatigue are not classic signs of an AMI, but they can be symptoms of an AMI in some older men. Dyspnea and fatigue may be attributed to aging, deconditioning, or other chronic diseases, but they can also indicate reduced oxygen supply to the heart and the body.
Choice D reason: Vague complaints are not classic signs of an AMI, but they can be symptoms of an AMI in some older men. Vague complaints may include anxiety, restlessness, nausea, dizziness, or weakness, which may be overlooked or dismissed as minor ailments, but they can also indicate a serious cardiac event.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the classic sign of an AMI that can be absent in an older man with an AMI.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today