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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This response is a straightforward denial. It reflects a direct and possibly automatic answer that the client does not use recreational drugs. However, this type of response might be influenced by the phrasing of the question, which could lead the client to respond in a way that aligns with what they perceive as socially acceptable or expected.
B. This response indicates that the client acknowledges past use of a recreational drug (marijuana) but minimizes its frequency and significance. The response suggests that the phrasing of the question might have led the client to clarify their past behavior, showing an attempt to be honest while downplaying the extent of use.

C. This response suggests that the client is seeking clarification on what the term "recreational drugs" includes. The question might have been vague or broad, prompting the client to ask for a definition or to specify which substances are considered recreational drugs. This response indicates that the client might be unsure about whether their drug use falls into the category of recreational drugs.
D. This response implies that the client does use recreational drugs but does so infrequently or sporadically. It suggests a level of acknowledgment of occasional use without providing specifics. This type of answer might reflect that the client is uncomfortable with a direct yes/no response and opts for a more ambiguous acknowledgment.

A. Perform a head-to-toe physical assessment. B. Prepare to collect a vaginal specimen for Papanicolaou smear. C. Collect information about the client's activities since surgery. D. Conduct a comprehensive review of systems.

Correct Answer is C

Explanation

A. At six weeks post-hysterectomy, a focused assessment that addresses the specific concerns related to the surgery and recovery would be more appropriate. A full physical examination might be too broad for this purpose, although aspects of it might be included if specific issues are identified.
B. A Pap smear is typically not required during a post-surgical follow-up for a hysterectomy unless there is a specific reason to screen for cervical cancer. In many cases, especially if the hysterectomy was for benign reasons and the cervix was removed, Pap smears might not be necessary.
C. This approach is highly relevant for a post-surgical evaluation. Gathering information about the client’s activities since surgery helps assess the recovery process, identify any issues or complications, and provide appropriate advice for ongoing care. Activities might include physical activity levels, adherence to post-surgical instructions, any new symptoms, and overall well-being.
D. A comprehensive review of systems is a thorough approach to identifying any potential issues across various body systems. While this can be useful in some cases, it may be more extensive than necessary for a routine follow-up after a hysterectomy.

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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

While performing a health history the nurse asks the client, "You don't use recreational drugs, do you?" This approach is most likely to elicit which response from the client?

Correct Answer is A

Explanation

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Correct Answer is C

Explanation

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Patient Data Exhibits

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

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During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

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