To best identify a risk for injury in an older adult patient, the nurse assesses for
a. decreased muscle mass in the legs.
b. history of falls.
c. hyperextension of the spine.
d. decreased bone density.
B
Musculoskeletal aging changes increase the risk for falls in older adults. Approximately one third of those age 65 or older have falls each year. About 2% of this group is hospitalized as a result of injuries incurred during the fall. The other assessments are appropriate, but a history of falls is most predictive.
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The patient has a pressure ulcer that was classified as a stage III ulcer. With care, the ulcer has partially healed and now appears as an area of nonblanchable erythema with mild edema. What is the most appropriate nursing description?
A) Stage I ulcer B) Stage III ulcer, healing C) Stage III to I ulcer D) Stage III ulcer, exacerbated
The PACU nurse would identify which assessment finding as abnormal in a client recovering from surgery?
a. Gag reflex present b. Pulse oximeter reading of 84% c. Breath sounds in all lobes d. Negative Homans' sign
The nurse is performing discharge teaching for the parents of a child who had a tonsillectomy. Which of the following instructions would be most appropriate to include?
A) "Call the doctor immediately if you see dark reddish-brown blood in his vomit." B) "Get him to drink orange juice or iced tea to help soothe his sore throat." C) "Try using an ice collar or ice chips to make him more comfortable." D) "Encourage him to cough and clear his throat to remove any dried mucus."
Which question should the nurse ask when assessing a 60-year-old patient who has a history of benign prostatic hyperplasia (BPH)?
a. "Have you noticed any unusual discharge from your penis?" b. "Has there been any change in your sex life in the last year?" c. "Has there been a decrease in the force of your urinary stream?" d. "Have you been experiencing any difficulty in achieving an erection?"