A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?
"I do my best to protect my skin from bumps and cuts. It's more fragile now."
"I guess feeling down is just part of aging."
"My hair is thinning. I'm going to go to the wig shop soon."
"I missed my eye appointment, but I rescheduled it."
The Correct Answer is B
Choice A reason: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.
Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.
Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.
Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 24/min is slightly higher than the normal range (12-20 breaths per minute) and does not necessarily indicate the effectiveness of furosemide in treating pulmonary edema.
Choice B reason: Adventitious breath sounds, such as crackles or wheezes, are often present in pulmonary edema and would not indicate that the furosemide is effective. The resolution of these sounds would be a better indicator of improvement.
Choice C reason: Weight loss of 1.8 kg (4 lb) in the past 24 hours likely indicates a reduction in fluid retention, which is a desired effect of furosemide in the treatment of pulmonary edema. This diuretic effect reduces the fluid overload, thereby improving the symptoms of pulmonary edema.
Choice D reason: An elevation in blood pressure is not an expected outcome of effective furosemide therapy for pulmonary edema. Furosemide is a diuretic and would more likely lead to a reduction in blood pressure due to fluid loss.
Correct Answer is C
Explanation
Choice A reason: Tapping the client's facial nerve and noting any facial twitching is not a specific assessment for bacterial meningitis. This action is more related to evaluating facial nerve function and is not typically used to diagnose meningitis.
Choice B reason: Striking the client's patellar tendon with a percussion hammer and noting any increase in response is a test for reflexes, which may or may not be altered in bacterial meningitis. An increased response can be seen in various neurological conditions and is not specific to meningitis.
Choice C reason: Gently elevating the client's head and noting any nuchal rigidity is a key part of the focused assessment for bacterial meningitis. Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and is assessed by gently lifting the head and attempting to move the chin toward the chest. If the client resists due to pain or stiffness, this could indicate nuchal rigidity associated with meningitis.
Choice D reason: Running a tongue blade on the outside of the client's sole and noting any flaring of the toes, known as the Babinski sign, is used to assess for central nervous system lesions and is not specific to meningitis. While it can be part of a neurological assessment, it does not specifically indicate bacterial meningitis.
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