A nurse at a provider's office is collecting physical data from an older adult client. Which of the following images should the nurse identify as an example of an expected age-related change?
A
B
C
D
The Correct Answer is D
A. Close-up of eyes with yellow sclera: Could indicate jaundice or liver dysfunction, which is not an expected part of aging and requires further evaluation.
B. Older adult man with a rounded back and head tilted forward: Suggests kyphosis, which can occur with aging but is usually linked to osteoporosis or vertebral fractures, not considered an inevitable, expected change.
C. Close-up of nose with a reddish-purple spot (possible bruise): Might result from trauma, coagulopathy, or medication side effects like anticoagulants, not a routine age-related change.
D. Hands with prominent veins, thin skin, and wrinkles: Thinning skin due to decreased subcutaneous fat. Wrinkles from reduced skin elasticity. Prominent veins due to loss of skin turgor and connective tissue. These are all normal physical findings in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Have the client perform heel-to-toe walking: Heel-to-toe walking (tandem gait) assesses balance and coordination by challenging the client’s ability to maintain stability during a narrow base of support. Difficulty with this test can indicate problems with cerebellar function or proprioception, which are essential for balance.
B. Perform Weber’s test: Weber’s test evaluates hearing by assessing bone conduction and is not related to balance assessment. It helps differentiate between conductive and sensorineural hearing loss but does not provide information about vestibular function.
C. Check for a positive Babinski reflex: Babinski reflex testing assesses neurological function of the corticospinal tract but does not evaluate balance. A positive Babinski indicates upper motor neuron damage but is unrelated to equilibrium or postural control.
D. Perform the Romberg test: The Romberg test evaluates proprioception and balance by assessing the client’s ability to maintain standing posture with eyes closed. A positive Romberg sign suggests impaired proprioception or vestibular dysfunction affecting balance.
E. Have the client lie in bed and use his heel to draw a line on the opposite shin: This test evaluates coordination and proprioception, important components of balance, by assessing precise lower limb control. Difficulty performing this task may indicate issues with neuromuscular control or proprioception.
Correct Answer is C
Explanation
A. "The lower end of the sling goes below the client's calves." The lower end of the sling should support the thighs and buttocks but typically does not extend below the calves. Positioning the sling incorrectly can cause discomfort or injury during the lift.
B. "The sides of the sling are for the client to hold on to." While some slings have loops for the caregiver to grasp, clients usually do not hold onto the sling sides during the lift, as this could interfere with safe handling and stability.
C. "This type of device is useful for a client who cannot assist." Mechanical lifts are specifically designed to safely transfer clients who have little or no ability to assist with moving. This reduces injury risk for both client and caregiver and ensures safe mobility.
D. "The device requires the client to use upper body strength." Mechanical lifts minimize the need for client effort, especially upper body strength. They are intended for clients unable to bear weight or assist, so reliance on client strength contradicts the device’s purpose.
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