The nurse is assessing older adult clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

A change in awareness of surroundings.

Reduced fine motor skills.

A negative Babinski reflex.

Diminished short term memory over the past year.

Answer and Explanation

The Correct Answer is A

A. A change in awareness of surroundings: Altered awareness or sudden changes in level of consciousness can signal acute neurological issues such as stroke, brain injury, infection, or metabolic imbalances. This is a serious red flag requiring immediate medical evaluation to prevent potential deterioration.

B. Reduced fine motor skills: While reduced fine motor skills can indicate a neurological issue, it typically develops gradually due to conditions like arthritis, neurological disorders, or aging and may be monitored unless associated with other acute symptoms. It is not usually an emergency unless sudden in onset.

C. A negative Babinski reflex: A negative Babinski reflex is a normal finding in adults, indicating intact central nervous system function. It does not suggest the need for medical follow-up in the absence of other abnormal signs.

D. Diminished short term memory over the past year: Gradual memory decline may indicate cognitive changes like dementia, stress or early signs of cognitive impairment but it typically requires routine, not immediate, follow-up unless there's a rapid worsening or associated concerning symptoms.

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Correct Answer is D

Explanation

A. A dark line of pigmentation occurs along the midline of the abdomen: This refers to linea nigra, which is more commonly associated with hormonal changes during pregnancy rather than puberty. It is not a typical sign of puberty in adolescent females.

B. Weight gain becomes obvious as the hip circumference increases: While changes in body shape and fat distribution occur during puberty especially with increased fat around the hips and thighs, it is usually a gradual process and not the first noticeable sign.

C. The areolar color of the nipples changes from pink to dark brown: Areolar pigmentation may darken with puberty in some individuals, but it varies by skin tone and is not a reliable or universal first sign of puberty.

D. The development of breast buds will form under the nipples: The appearance of breast buds or thelarche, small, firm lumps form under the nipples, which can sometimes be tender, is typically the first visible sign of puberty in girls, usually occurring around ages 8–13. It signals the beginning of hormonal changes and physical development.

A. Right breath sounds louder than left. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Blowing, hollow sounds above sternum.

Correct Answer is D

Explanation

A. Right breath sounds louder than left: While there might be slight variations, breath sounds should generally be equal in intensity on both sides of the chest. Breath sounds should be relatively equal bilaterally. Asymmetry in sound intensity can indicate consolidation, obstruction, or a pneumothorax.

B. Slight crackling throughout lung fields: Crackles (rales) are abnormal sounds typically associated with fluid in the alveoli, as seen in conditions like heart failure, pneumonia, or pulmonary fibrosis. They are not a normal finding in healthy lung tissue.

C. Faint whistling over both lung bases: Whistling or high-pitched sounds suggest wheezing, often caused by narrowed airways due to asthma, bronchitis, or other obstructive airway diseases. This is considered an abnormal finding.

D. Blowing, hollow sounds above sternum: These describe bronchial breath sounds, which are normally heard over the trachea and manubrium (above the sternum). They have a blowing, hollow quality and are considered a normal finding in that location.

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The nurse is assessing older adult clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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