Question

An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling?

A. Dry oral mucous membranes
B. Orthostatic blood pressure changes
C. Pulse rate of 72 beats/min and bounding
D. Serum potassium level of 4.0 mEq/L

Answer 1

Dry oral mucous membranes and orthostatic blood pressure changes are nursing assessment data that identify an older adult client's risk for falling.

Step-by-step explanation:

The nursing assessment data that identify an older adult client's risk for falling are:

• Dry oral mucous membranes: Dehydration can lead to dryness of the oral mucosa, making it more difficult to speak or swallow.
• Orthostatic blood pressure changes: Orthostatic hypotension, a sudden drop in blood pressure when standing up, can increase the risk of falling.

The other options are not directly related to the risk of falling. A pulse rate of 72 beats/min and bounding is within the normal range, and a serum potassium level of 4.0 mEq/L is also within the normal range.