The practical nurse (PN) is evaluating clinical scenarios involving older adult clients in a subacute care unit. Which of the following nursing interpretations or interventions demonstrate a correct understanding of physiological aging, safety management, and atypical disease presentation? (Select all that apply.)
- Recognizing that an 85-year-old client with acute pneumonia may present with new-onset falls and altered mental status instead of a high fever and productive cough.Cevap
- BDocumenting a 90-year-old client's abrupt development of profound disorientation and pacing as an expected manifestation of senile cognitive decline.
- Interpreting a frail older adult's oral temperature of 99.0°F (37.2°C) accompanied by lethargy and anorexia as a potential medical emergency requiring immediate report to the registered nurse.Cevap
- DInitiating the use of a vest restraint for a wandering client with dementia to prevent falls, prior to evaluating the effectiveness of a bed alarm and scheduled toileting.
- Implementing high-contrast color coding on step edges and ensuring glare-free lighting to compensate for a client's age-related yellowing of the ocular lens and decreased depth perception.Cevap
- FDismissing a postoperative older adult's borderline tachycardia and slight hypotension as a normal age-related cardiovascular response rather than reporting these early signs of potential shock.
Cevap
The correct interpretations include recognizing atypical presentations of pneumonia (falls/altered mental status), understanding that low-grade temperatures (99.0°F) in frail adults can signal severe infection, and implementing environmental modifications (high-contrast edges, glare-free lighting) for expected visual changes.
The correct options demonstrate a mastery of geriatric care principles. Older adults often exhibit atypical presentations of infections, such as pneumonia presenting with falls, altered mental status, or lethargy rather than typical respiratory symptoms. Additionally, due to age-related decreases in basal body temperature, a low-grade fever (e.g., 99.0°F or 37.2°C) combined with functional decline can indicate a serious systemic infection. Correct safety management includes compensating for normal visual aging changes by providing high-contrast edges and glare-free lighting.
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Atypical Disease Presentation and Physiological Aging
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