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 C

Explanation

A. Capillary refill less than 3 seconds: This is considered a normal finding, indicating good peripheral perfusion. It does not correlate with clubbing, which is typically a chronic sign of systemic hypoxia rather than acute perfusion issues.

B. 3+ peripheral dependent edema: Edema is often associated with heart failure or venous insufficiency, not necessarily with clubbing. While both can occur in cardiopulmonary conditions, edema is not a direct indicator or cause of nail clubbing.

C. Oxygen saturation of 85%: This value is significantly low and indicates chronic hypoxemia, which is strongly associated with clubbing of the fingers or toes. Chronic low oxygen levels, as seen in conditions like COPD or congenital heart disease, stimulate tissue changes that result in clubbing.

D. Absent deep tendon reflexes: This finding is typically associated with neurological conditions such as peripheral neuropathy or spinal cord injury., not with hypoxia or diseases causing clubbing. It does not have a physiologic link to nailbed changes.

A. Ecchymosis. B. Hematoma. C. Petechiae. D. Vesicle.

Correct Answer is C

Explanation

A. Ecchymosis: Ecchymosis refers to larger areas of bruising or discoloration due to bleeding under the skin, typically caused by trauma. It appears as purple or bluish patches but does not present as tiny pinpoint spots.

B. Hematoma: A hematoma is a localized collection of blood under the skin or tissue that results in swelling and discoloration. It is typically raised and larger than petechiae, often caused by blunt force trauma.

C. Petechiae: Petechiae are small, pinpoint, round red or purple spots caused by minor bleeding under the skin. They are flat, do not blanch with pressure, and are often associated with pressure or trauma. In the context of intimate partner violence, petechiae can be a sign of strangulation or other abuse-related injuries.

D. Vesicle: A vesicle is a small, fluid-filled blister on the skin, commonly associated with infections like herpes or chickenpox. They appear as a raised lesion containing clear fluid. It is not red or pinpoint in appearance and would not match the described findings in this scenario.

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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

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is C

Explanation

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is C

Explanation

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