Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls?

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Question 1 of 5

Which of these nursing diagnoses, appropriate for elderly clients, would indicate the client is at greatest risk for falls?

Correct Answer: A

Rationale: Sensory perceptual alterations related to decreased vision indicates the greatest fall risk in the elderly. Vision loss impairs navigation, per gerontological nursing. Gas exchange and nocturia contribute less directly. A targets the primary hazard.

Question 2 of 5

The nurse is caring for a client who is receiving total parenteral nutrition (TPN) (hyperalimentation and lipids). What is the priority nursing action on every 8 hour shift?

Correct Answer: C

Rationale: Monitoring for glucosuria and ketosis detects hyperglycemia or fat metabolism issues, critical with TPN.

Question 3 of 5

The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?

Correct Answer: D

Rationale: Fever may indicate infection at the access site, a medical emergency in dialysis patients.

Question 4 of 5

The nurse is administering diltiazem (Cardizem) to a client. Prior to administration, it is important for the nurse to assess which parameter?

Correct Answer: B

Rationale: Diltiazem, a calcium channel blocker, lowers blood pressure; hypotension is a key risk to assess.

Question 5 of 5

An elderly client is on an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease. The nurse would suggest a spacer to

Correct Answer: C

Rationale: Spacers aid coordination, ensuring more drug reaches the lungs in elderly patients.

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