A nurse is caring for a patient with presbycusis. Which ...

[vinney12]

A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
 
  a. The patient frequently cleans out eyes with saline washes.
  b. The patient applies different spices during mealtime to food.
  c. The patient turns one ear toward the nurse during conversation.
  d. The patient isolates self from social situations with groups of people.

Question 2

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)
 
  a. Can you easily change your position?
  b. Do you have sensitivity to heat or cold?
  c. How often do you need to use the toilet?
  d. What medications do you take?
  e. Is movement painful?
  f. Have you ever fallen?

[popopong]

Answer to Question 1

ANS: C
Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive.

Answer to Question 2

ANS: A, B, C, E
Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.

[vinney12]

TYSM

[robbielu01]

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