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. Right side deep tendon reflex 2+: A 2+ reflex is considered normal and would not correlate with the nurse’s observation of diminished reflexes. Documenting 2+ would fail to reflect the neurological deficit noted in the assessment.

B. Right side deep tendon reflex 0: A 0 reflex indicates complete absence of a response, suggesting flaccid paralysis or severe lower motor neuron damage. The nurse observed diminished reflexes, not absent, so 0 would overstate the impairment.

C. Right side deep tendon reflex 4+: A 4+ reflex indicates hyperreflexia, often associated with upper motor neuron lesions, not weakness and diminished reflexes. This would contradict the nurse’s findings of decreased neuromuscular activity on the right side.

D. Right side deep tendon reflex 1+: A 1+ rating represents diminished or hypoactive reflexes, which aligns with the nurse’s findings of generalized weakness and reduced deep tendon activity. This accurately reflects the likely residual neurological effects post-CVA.

A. "Refrain from eating or drinking for at least thirty minutes." B. "Lie in a prone position with slightly flexed knees." C. "Empty your bladder just prior to the examination." D. "Exhale slowly through your mouth then hold your breath."

Correct Answer is C

Explanation

A. "Refrain from eating or drinking for at least thirty minutes. There is no strict requirement for fasting before a standard abdominal exam unless it's for a diagnostic procedure like an ultrasound. Eating or drinking within 30 minutes does not typically interfere with the physical assessment of the abdomen.

B. "Lie in a prone position with slightly flexed knees." The prone position (lying face down) is not appropriate for an abdominal exam. The correct position is supine (lying on the back) with knees slightly flexed to help relax abdominal muscles and enhance comfort during palpation.

C. "Empty your bladder just prior to the examination." An empty bladder helps reduce discomfort and allows for more accurate palpation and assessment of abdominal organs. A full bladder can distort findings and interfere with the nurse’s ability to assess lower abdominal structures properly.

D. "Exhale slowly through your mouth then hold your breath." While breathing techniques may be used during specific parts of the assessment (e.g., liver palpation), this instruction is not the first or primary preparation step. Emptying the bladder takes priority to ensure accuracy and comfort.

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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 observes generalized weakness and diminished deep tendon reflexes on the right side of an older adult client who has a history of a cerebrovascular accident. Which deep tendon reflex response should the nurse document to support the client's clinical assessment?

Correct Answer is D

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Correct Answer is C

Explanation

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