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

Diminished short term memory over the past year.

Reduced fine motor skills.

A negative Babinski reflex.

A change in awareness of surroundings.

Answer and Explanation

The Correct Answer is D

A.   Diminished short-term memory in older adults can be a sign of normal aging or early cognitive decline, such as mild cognitive impairment or early-stage dementia. While this is concerning, it is not typically an immediate indicator requiring urgent medical follow-up. It is important to monitor and assess memory changes over time, but it might not necessitate immediate action unless accompanied by other significant symptoms.
B.   Reduced fine motor skills can occur due to aging, arthritis, or neurological conditions such as Parkinson's disease. While this finding is important for evaluating the client's functional status and quality of life, it does not usually require immediate medical follow-up unless it is sudden, severe, or accompanied by other alarming symptoms.

C.   The Babinski reflex is a neurological test where stroking the sole of the foot causes the big toe to extend. In adults, a negative Babinski reflex (where the big toe does not extend) is normal and indicates that the corticospinal tract is functioning properly. A positive Babinski reflex is abnormal in adults and may indicate neurological damage.
D.   A change in awareness of surroundings is a more urgent concern. It could indicate acute cognitive changes, delirium, or severe neurological issues that require prompt evaluation. Such changes can be related to various serious conditions, including infections, metabolic imbalances, or acute brain disorders.

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Correct Answer is D

Explanation

A. Inequality in muscle contraction is not related to the monofilament test, which assesses sensation rather than muscle strength or contraction. This finding would be more relevant to a neurological or musculoskeletal assessment rather than a sensory test.
B. An intention tremor is a type of tremor that occurs when a person is trying to make a precise movement, often associated with conditions affecting the cerebellum. This is not related to the monofilament test, which measures sensory perception and not motor function or tremors.

C. Slowed capillary refill is a sign of poor peripheral circulation and is assessed by pressing on the nail bed or skin and observing how long it takes for color to return. While it is important for assessing blood flow, it is not directly related to the monofilament test, which evaluates sensory function.
D. Loss of peripheral sensation is a direct and relevant finding for an abnormal response on the monofilament test. The monofilament test is designed to detect loss of sensation in the feet, which can be an indicator of diabetic neuropathy. An abnormal result, such as the inability to feel the monofilament or diminished sensation in certain areas, would indicate that the client is experiencing peripheral neuropathy.

A. 15 lb (6.8 kg) weight loss. B. Diminished appetite. C. Decreased height. D. Lower body mass index (BMI)

Correct Answer is C

Explanation

A. Significant weight loss can be a concern for overall health and may be related to various conditions, including nutritional deficiencies. However, weight loss alone does not specifically indicate the need for bone density screening. It may be a factor in a broader health assessment but is not a direct indicator for bone density measurement.
B. A diminished appetite can affect nutritional intake, which in turn may impact bone health over time. However, diminished appetite itself does not directly suggest a need for a bone density screening unless it leads to significant weight loss or is part of a broader concern about nutritional status affecting bone health.
C. Decreased height is a key indicator that may suggest osteoporosis or significant bone loss. This can be due to vertebral compression fractures, which are common in individuals with osteoporosis. A reduction in height over time can be a direct sign that warrants a bone density screening to assess bone health and risk for fractures.
D. A lower BMI can be associated with lower bone mass and increased risk for osteoporosis, particularly in individuals who are underweight. However, while a low BMI can be a risk factor for osteoporosis, it is not as specific as decreased height for prompting a bone density screening.

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The nurse is assessing older 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 C

Explanation

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