What is the most effective intervention to prevent skin breakdown in immobile older adults?

Correct Answer: C

Rationale: The correct answer is C because regular repositioning and the use of pressure-relieving devices are essential to prevent skin breakdown in immobile older adults. Repositioning helps redistribute pressure, maintaining blood flow to the skin and preventing tissue damage. Pressure-relieving devices such as cushions or special mattresses further reduce pressure on vulnerable areas. Choices A and B do not address the root cause of skin breakdown and may even exacerbate the issue. Choice D is incorrect as complete bed rest can lead to further complications like pressure ulcers. In summary, choice C is the most effective intervention as it directly targets the risk factors for skin breakdown in immobile older adults.

Correct Answer: C, D, E

Rationale: The correct answers are C, D, and E. C is crucial as it allows for effective communication, D involves observing nonverbal cues, and E emphasizes the need for clear and concise language. A is incorrect as the nurse should address the client directly, not just the interpreter. B is incorrect as using technical terms may hinder understanding.

Correct Answer: C

Rationale: The correct answer is C: Social engagement and support. Social engagement has been identified as a crucial factor in successful aging, as it contributes to emotional well-being, cognitive function, and overall quality of life. Older adults with strong social networks tend to have better physical and mental health outcomes. Social support can help individuals cope with stress, reduce feelings of loneliness and isolation, and provide a sense of purpose and belonging. Financial security (A) is important but not the most significant predictor. Physical fitness and health (B) are essential but do not solely determine successful aging. Mental resilience (D) is valuable, but the social aspect plays a more significant role in aging successfully.

Correct Answer: D

Rationale: The correct answer is D: Confusion or cognitive decline. In older adults, dehydration can manifest differently than in younger populations. Cognitive decline is a key sign of dehydration in older adults due to the brain being more sensitive to fluid loss. Dehydration can lead to confusion, disorientation, and impaired cognitive function in older individuals. Dark-colored urine (A) is a common sign of dehydration in all age groups. Increased thirst (B) is a general sign of dehydration but may not be as prominent in older adults due to decreased thirst sensation. Dry mouth and skin (C) are also common signs of dehydration but may not be as reliable indicators in older adults compared to cognitive changes.

Correct Answer: B

Rationale: The correct answer is B: Increased risk of falls. Benzodiazepines are central nervous system depressants that can cause drowsiness, dizziness, and impaired coordination, leading to an increased risk of falls in older adults. This is due to the sedative effects of benzodiazepines, which can affect balance and motor skills. Increased alertness (choice A) is not a common side effect of benzodiazepines, as they typically have a calming and sedating effect. Improved memory (choice C) is also unlikely, as benzodiazepines are more commonly associated with memory impairment. Enhanced muscle strength (choice D) is not a known side effect of benzodiazepines, as they do not directly affect muscle strength. In summary, the correct answer is B because benzodiazepines can increase the risk of falls in older adults due to their sedative properties.

Correct Answer: B

Rationale: The correct answer is B: dehydration. Mr. J's symptoms of flu-like illness, diarrhea, vomiting, confusion, lethargy, dry skin, brown tongue, sunken cheeks, and concentrated urine are indicative of severe dehydration. Dehydration can lead to electrolyte imbalances, decreased blood volume, and impaired organ function, resulting in confusion and lethargy. Skin changes, dry mucous membranes, and concentrated urine are also classic signs of dehydration. The other choices (A, C, D) do not align with the constellation of symptoms presented by Mr. J and are less likely based on the information provided.

Correct Answer: D

Rationale: The correct answer is D: Circulatory problems related to age and a chronic illness. Severe edema, hair loss on the legs, and foot ulcerations are indicative of poor circulation, often seen in conditions like peripheral artery disease. Age and chronic illnesses can contribute to circulatory issues. A diet low in protein (choice A) would not directly cause these symptoms. Exposure to cold (choice B) would not explain the specific symptoms mentioned. Frequent falls (choice C) do not align with the symptoms provided.

Correct Answer: A

Rationale: The correct answer is A: Unsecured scattered rugs. This requires immediate nursing action as it poses a significant fall risk for the older adult. Rugs can cause tripping hazards, leading to potential injuries. The nurse should secure or remove the rugs to ensure the safety of the patient. Summary of other choices: B: Operable smoke detector - While important for safety, it does not require immediate nursing action as it is already in working condition. C: Prefilled medication cassette - This is not an immediate safety concern and can be addressed during routine medication management. D: Unsecured scattered rugs (repeated) - This choice is the same as the correct answer, so it is incorrect.

Correct Answer: B

Rationale: The correct answer is B: Malnutrition and dehydration. Malnutrition and dehydration are major risk factors for pressure ulcers in older adults because they can lead to poor skin integrity, reduced tissue resilience, and impaired wound healing. Lack of sleep (choice A) may contribute to overall health issues but is not a direct risk factor for pressure ulcers. Excessive physical activity (choice C) can increase the risk of injury but does not directly cause pressure ulcers. High blood pressure (choice D) is a risk factor for cardiovascular issues but is not specifically linked to the development of pressure ulcers.