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Zorluk: OrtaHealth Screening

A home health registered nurse is developing a care plan for a 78-year-old client who recently transitioned to living with their adult children. Which of the following actions should the nurse include in the client's comprehensive health screening plan? Select all that apply.

  1. Administer the Timed Up and Go (TUG) test to evaluate mobility and fall risk.Cevap
  2. Utilize the Geriatric Depression Scale (GDS) to screen for mood alterations.Cevap
  3. C
    Defer cognitive assessments if the family reports the client's recent memory lapses are a normal part of getting older.
  4. D
    Schedule a routine colonoscopy as a primary prevention measure for colorectal cancer.
  5. Perform basic auditory and visual acuity testing to identify sensory impairments.Cevap
  6. F
    Delegate the initial comprehensive nutritional risk screening to the unlicensed assistive personnel (UAP).

Cevap

The nurse should administer the Timed Up and Go (TUG) test, utilize the Geriatric Depression Scale (GDS), and perform basic auditory and visual acuity testing.
Comprehensive geriatric screening requires prioritizing assessments that impact safety, functional status, and quality of life. The Timed Up and Go (TUG) test accurately evaluates mobility and fall risk. The Geriatric Depression Scale (GDS) is necessary because depression is prevalent yet often underdiagnosed in older adults, especially following major life transitions. Auditory and visual screenings are vital because sensory deficits contribute heavily to falls and cognitive decline.

Adım Adım Çözüm

1
Analyze the client's demographic and situational context.
The client is 78 years old and recently underwent a major life transition (moving in with adult children).
Understanding the client's age and psychosocial stressors helps identify the highest priority health screenings.
2
Evaluate each screening action for appropriateness in the geriatric population.
Mobility (TUG), depression (GDS), and sensory (vision/hearing) screenings are evidence-based, high-priority assessments for older adults.
These screenings detect early signs of functional decline, fall risk, and mental health alterations.
3
Identify contraindicated or incorrect nursing actions among the choices.
Deferring cognitive assessment ignores potential pathology. Labeling a colonoscopy as primary prevention is a terminology error. Delegating initial assessment to a UAP violates nursing scope of practice.
Ensuring safe and effective care requires differentiating between correct screening protocols, accurate prevention levels, and proper delegation guidelines.

Anahtar Kavram

Geriatric Health Screening and Assessment
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Konular

Health Screening

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