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

A. Defecation less than once each day is not necessarily constipation.

Explanation: The frequency of bowel movements varies among individuals, and defecating less than once each day does not necessarily indicate constipation. Normal bowel habits can differ, and what is considered regular for one person may not be the same for another. Constipation is better assessed by considering other factors such as stool consistency, straining during bowel movements, and feelings of incomplete evacuation.

B. Leaking liquid feces should be treated as diarrhea.

Explanation: Leaking liquid feces may be indicative of diarrhea, but it is not the only factor to consider. The cause of diarrhea should be investigated, and treatment will depend on the underlying reason, which may include infections, medications, or other medical conditions.

C. Mineral oil is recommended as a laxative for the older adult.

Explanation: Mineral oil is generally not recommended as a laxative for older adults. It can interfere with the absorption of fat-soluble vitamins and may have adverse effects. There are other safer and more effective laxative options that healthcare providers may recommend.

D. Excessive sleep can be a symptom of constipation.

Explanation: Excessive sleep is not typically considered a symptom of constipation. Constipation is more commonly associated with symptoms such as infrequent bowel movements, difficulty passing stool, and abdominal discomfort. Sleep disturbances may have various causes, but they are not a direct symptom of constipation.

A. "As the health care proxy, you are the one who makes the decisions. Let's call your mom's doctor."
Explanation: This response inaccurately suggests that the health care proxy has the authority to make decisions even when the client has decision-making capacity. The focus should be on the client's autonomy.

B. "I understand why you are so upset. I don't think she is doing the right thing either. Let us think together how we can change her mind."
Explanation: This response is inappropriate as it involves the nurse expressing a personal opinion and attempting to influence the client's decision. The nurse's role is to support the client's autonomy and facilitate communication between the client and their family.

C. "You will need to go to court and be declared a guardian."
Explanation: Involving the court and seeking guardianship is not warranted when the client has decision-making capacity. This option is not aligned with the principles of respecting the client's autonomy and decision-making capacity.

D. "Health care proxies only come into play when the individual can no longer make their own decisions. Your mother is able to make her own decisions. I suggest you talk with her."
Explanation: In this scenario, the client is cognitively intact and has decision-making capacity. As long as the older adult is able to make their own decisions, the health care proxy's role is not activated. The nurse appropriately advises the daughter to communicate directly with her mother about her concerns and decisions. This respects the autonomy of the client, who has the right to make decisions about their own healthcare as long as they have the capacity to do so.