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 A
Explanation
Choice A reason: Awakens with periodic left-foot numbness is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it may indicate peripheral neuropathy, which is a common complication of diabetes. Peripheral neuropathy is a nerve damage that affects the feet and legs, causing numbness, tingling, pain, or weakness. Peripheral neuropathy can increase the risk of foot ulcers, infections, and amputations. The nurse should educate the older adult about the importance of regular foot care, blood sugar control, and medication adherence.
Choice B reason: Enjoys spicy food more than bland food is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a personal preference that does not affect the blood glucose levels. However, the nurse should advise the older adult to limit the intake of salt, fat, and sugar, and to follow a balanced and nutritious diet that meets their needs and preferences.
Choice C reason: Has difficulty hearing conversations in crowded rooms is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's hearing ability and provide appropriate aids and strategies to enhance their communication and socialization.
Choice D reason: Requires reading glasses at 2.0 strength is not an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar, as it is a common age-related change that does not affect the blood glucose levels. However, the nurse should assess the older adult's vision and provide appropriate aids and strategies to improve their safety and quality of life.
Choice E reason: None of the above is not the correct answer, as there is one choice that is an alteration in sensory function that the nurse should address in the plan of care for stabilizing the blood sugar.
Correct Answer is D
Explanation
Choice A reason: A detached retina is a serious condition that occurs when the retina, the light-sensitive layer of tissue at the back of the eye, separates from its underlying support tissue. It can cause vision loss or blindness if not treated promptly. However, it does not usually cause intense headaches or bloodshot eyes, but rather flashes of light, floaters, or a curtain-like shadow over the visual field.
Choice B reason: Macular degeneration is a common eye disorder that affects the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, especially in the center of the visual field. However, it does not usually cause intense headaches or bloodshot eyes, but rather difficulty reading, recognizing faces, or seeing colors.
Choice C reason: Cataracts are cloudy areas in the lens of the eye that can impair vision. They are usually related to aging, but can also be caused by other factors such as diabetes, trauma, or radiation. They can cause blurred or dim vision, sensitivity to light, or halos around lights. However, they do not usually cause intense headaches or bloodshot eyes, but rather gradual and painless vision loss.
Choice D reason: Angle-closure glaucoma is a type of glaucoma that occurs when the drainage angle of the eye becomes blocked, causing a sudden increase in the pressure inside the eye. It can damage the optic nerve and lead to permanent vision loss if not treated immediately. It can cause intense headaches, bloodshot eyes, blurred vision, nausea, vomiting, or seeing rainbow-colored rings around lights. It is a medical emergency that requires immediate attention.
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