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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. While comparing the range of motion of both legs could be useful for detecting joint or muscle- related issues, it does not directly address the vascular concerns suggested by the shiny skin and absence of hair growth. These signs are more likely related to poor circulation, which requires different diagnostic approaches.
B. Asking about feelings of weakness or hunger may be more relevant to assessing the client’s blood glucose control, but it is not directly related to the symptoms of shiny skin and hair loss on the lower legs, which suggest peripheral vascular changes common in diabetes.
C. While measuring blood glucose levels is important in managing diabetes, it will not help to assess the vascular insufficiency suggested by the physical findings. However, managing blood glucose is crucial to preventing further complications.
D. Palpating the dorsalis pedis pulses is the most appropriate next step. Decreased or absent pulses in the feet and lower extremities are commonly associated with peripheral vascular disease, which is common in clients with diabetes due to poor circulation.

A. Brudzinski reflexes B. Muscle tone C. Romberg's test D. Level of consciousness E. Pupil size F. Cranial nerves G. Glasgow coma scale

Correct Answer is ["B","C","D","E","F","G"]

Explanation

A. Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B. Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C. This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D. Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E. Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F. Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G. The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Correct Answer is ["B","C","D","E","F","G"]

Explanation

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