A nurse is assessing an older adult client.
Which of the following findings should the nurse expect?
Increased sensitivity to touch.
Increase in cerumen in the ear canal.
Increased peripheral vision.
Increase in size of pupils.
The Correct Answer is B
Choice A rationale:
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
Choice C rationale:
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
Choice D rationale:
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
Choice B rationale:
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."
Choice A rationale:
- Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
- Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
- It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.
Choice B rationale:
- Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
- Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
- Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.
Choice C rationale:
- While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
- The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
- More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.
Choice D rationale:
- Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
- Other potential symptoms of diabetic retinopathy include:
- Blurred vision
- Floaters (dark specks or strings that move across the visual field)
- Difficulty seeing at night or in low light
- Loss of central vision
- Distortion of colors
- Blind spots
Correct Answer is C
Explanation
Choice A rationale:
The "Region" in the PQRST mnemonic refers to the location of the pain. It helps identify where the pain is occurring in the body. While this information is important, it does not address the quality or nature of the pain, which is what the nurse is asking the client to describe.
Choice B rationale:
"Severity" in the PQRST mnemonic relates to how intense the pain is. It helps in assessing the degree of pain the client is experiencing, but it does not address the quality or nature of the pain, which is what the nurse is inquiring about.
Choice C rationale:
"Quality" in the PQRST mnemonic pertains to the description of the pain itself. It helps the nurse understand the characteristics of the pain, such as whether it is sharp, dull, burning, throbbing, etc. This information is essential for a more accurate assessment of the pain's underlying cause, making it the correct choice in this scenario.
Choice D rationale:
"Precipitating cause" in the PQRST mnemonic is concerned with what factors or actions might trigger the pain. While this information is valuable, it does not directly address the nature or quality of the pain, which is what the nurse is trying to assess.
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