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 A

Explanation

A. Review the client's medication list: Certain medications such as opioids, cholinergics, or miotic eye drops can cause pupillary constriction and sluggish reactivity. Reviewing the client’s medication profile can help determine if the abnormal pupillary response is pharmacologically induced or a sign of a neurological problem.

B. Assess the client's visual fields: Visual field testing evaluates peripheral vision and is not directly related to assessing pupillary response. This would not provide immediate insight into the cause of constricted pupils and is not the priority action in this situation.

C. Brighten the light in the client's room: While lighting can affect pupil size during assessment, constricted pupils with minimal response typically indicate an internal cause rather than poor lighting. Brightening the room may not significantly alter findings or explain the abnormal response.

D. Administer PRN saline eye solution: Saline eye drops may relieve dryness or irritation but have no effect on pupil size or reactivity. Administering them does not address the root cause of constricted pupils and could delay proper assessment and treatment.

A. Percuss diaphragmatic excursion. B. Palpate tactile fremitus on the posterior chest. C. Observe the appearance of the thorax. D. Auscultate the client's breath sounds.

Correct Answer is C

Explanation

A. Percuss diaphragmatic excursion: Percussion of diaphragmatic excursion helps evaluate the movement of the diaphragm during respiration but does not directly confirm the physical appearance or structural change associated with a barrel chest.

B. Palpate tactile fremitus on the posterior chest: Tactile fremitus assesses vibration transmission through lung tissue and can indicate consolidation or air trapping, but it is not useful for visually confirming a barrel-shaped chest.

C. Observe the appearance of the thorax: A barrel chest is a visual and structural change where the chest appears rounded and expanded due to increased anterior-posterior (AP) diameter of the chest , often seen in chronic respiratory conditions like COPD. Observing the shape and configuration of the thorax is the most direct and accurate method to confirm this physical finding.

D. Auscultate the client's breath sounds: Auscultation reveals the presence or absence of breath sounds and abnormal respiratory patterns but does not provide confirmation of chest shape. It is valuable in assessing lung function, not thoracic structure.

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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

After checking a client's pupillary response to light, the practical nurse (PN) tells the registered nurse (RN) that the client's pupils are constricted with minimal response to light. Before verifying the PN's findings, which action should the RN take?

Correct Answer is A

Explanation

To confirm the presence of a barrel chest documented in the client's medical record, which action should the nurse take?

Correct Answer is C

Explanation

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

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

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?

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