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. Ask if the client often feels weak or hungry: While important in overall diabetes assessment, weakness or hunger are more related to poor glucose control and they do not specifically indicate peripheral vascular changes such as shiny skin and hair loss.

B. Compare the range of motion of both legs: Assessing range of motion can be useful in evaluating joint or muscular issues but does not provide specific information about vascular status or circulation, which is the primary concern here.

C. Measure the client's capillary glucose: Blood glucose levels are essential in managing diabetes but do not assess the presence or severity of peripheral vascular disease, which can lead to changes in skin and hair growth on the lower legs.

D. Palpate the client's dorsalis pedis pulses: Shiny skin and hair loss on the legs suggest poor peripheral circulation, often related to peripheral arterial disease, a common complication of diabetes mellitus. High blood sugar levels can damage blood vessels over time, leading to narrowing and reduced blood flow, particularly in the lower extremities. Palpating dorsalis pedis pulses helps assess arterial blood flow and supports evaluation of vascular insufficiency.

A. An odorless, red menstrual blood flow. B. Cramping associated with the amount of flow. C. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow. D. Blood saturation of one pad an hour.

Correct Answer is D

Explanation

A. An odorless, red menstrual blood flow: This is considered a normal characteristic of menstruation. Menstrual blood may have a slight metallic scent due to the mixing with vaginal secretions, but an odorless red flow is not a concern and does not suggest abnormality.

B. Cramping associated with the amount of flow: Mild to moderate cramping (dysmenorrhea) is a common and expected part of menstruation related to the release of prostaglandins that cause uterine contractions especially during heavier flow days. While it can be uncomfortable, it is not typically considered abnormal unless severe or disabling.

C. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow: Small blood clots can occur during menstruation, especially during heavier flow, and clots under 1 inch (2.5 cm) in diameter are generally not worrisome. This size is within normal limits and not an indication of a menstrual disorder.

D. Blood saturation of one pad an hour: This finding suggests menorrhagia, or abnormally heavy menstrual bleeding. Saturating a pad or tampon every hour for several consecutive hours is clinically significant and warrants further investigation, as it can lead to anemia and may signal an underlying gynecological issue such as fibroids or a bleeding disorder.

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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 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

The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client's current menstruation?

Correct Answer is D

Explanation

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?

When assessing a client's mouth, which finding requires immediate follow-up by the nurse?

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A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client?

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An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. Which does this finding indicate?