A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?
Increased risk for falling.
Expected results for an older adult.
Need for a walker to aid in ambulation.
Likely onset of Parkinson's disease.
The Correct Answer is A
A. A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B. While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C. The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D. The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as entering information directly in the client’s electronic medical record with appropriate organization
Choice B reason: Documenting at the nursing station may delay entry, increase the risk of errors or omissions, and reduce the opportunity for immediate clarification with the client. It is less ideal for capturing nuanced or time-sensitive information.
Choice C reason: Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
Choice D reason: Subjective data should be documented in the appropriate structured fields of the electronic medical record, not just in free-text note sections. This ensures the data is searchable, standardized, and usable for clinical decision-making and continuity of care.
Correct Answer is A
Explanation
A. A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B. While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C. The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D. The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.
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