The nurse has assessed the older adult client and has developed a nursing care plan based on the nurse's findings

Question

Which of the following age-related changes validates the nurse's inclusion of the nursing diagnosis Risk for Injury? Standard Text: Select all that apply. 1. The mucous membranes that line the respiratory passages become drier.
2. The client has developed bilateral cataracts.
3. The client has only three teeth in his mouth.
4. The client's body mass index (BMI) is 22.
5. The client has been diagnosed with hypothyroidism.

Answer 1

2,4,5
Rationale 1: The mucous membranes that line the respiratory passages become drier. The client with drier respiratory passages may have an increased risk of developing an infection.
Rationale 2: The client has developed bilateral cataracts. The client with bilateral cataracts will not be able to see as well. This client may have an increased risk of injury due to being unable to visualize obstacles or hazards.
Rationale 3: The client has only three teeth in his mouth. The client who has three teeth may not be able to receive adequate nourishment due to the inability to grind up the food with the teeth. Food must be chewed adequately for the body to be able to break down and gather nutrients from the food.
Rationale 4: The client's body mass index (BMI) is 22. The client who has a body mass index of 22 is underweight. This client has an increased risk of developing osteoporosis. This client may injure himself more during a fall than a client who has an ideal body weight.
Rationale 5: The client has been diagnosed with hypothyroidism. The client with hypothyroidism is more prone to injury because of delayed mental processing.