The nurse is performing a neurological assessment on the older adult. An expected finding is that:

Older adults are more likely to lose short-term memory first

Older adults have increased reflexes

Older adults have increased fine motor movement

Older adults are more likely to lose long-term memory first

Answer and Explanation

The Correct Answer is A

Choice A reason: Older adults commonly experience a decline in short-term memory as part of the normal aging process. This can make it more difficult to recall recent events or information.

Choice B reason: Older adults typically have decreased, not increased, reflexes due to changes in the nervous system.

Choice C reason: Older adults often experience a decline in fine motor movement, rather than an increase. Age-related changes can affect dexterity and coordination.

Choice D reason: Long-term memory is generally preserved longer in older adults compared to short-term memory. Older adults are more likely to have difficulties with recent memories.

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Correct Answer is D

Explanation

Choice A reason: The nurse waiting 5 minutes between administering prescribed eye drops is a standard practice to allow each drop to be properly absorbed and avoid dilution of the medication. This intervention does not require any action from the charge nurse.

Choice B reason: Leaving the eye shield in place while the client sleeps helps protect the eye from potential injury or infection after surgery. This is a recommended practice and does not need intervention from the charge nurse.

Choice C reason: Instructing the client not to drive at night is a reasonable precautionary measure given the client's recent eye surgery and potential vision changes. This instruction does not warrant intervention from the charge nurse.

Choice D reason: Encouraging the client to exercise with 20 lb weights one day post-operatively is inappropriate and requires the charge nurse to intervene. Strenuous activity can increase intraocular pressure and compromise the healing process after cataract surgery. The client should avoid heavy lifting and follow the post-operative care instructions provided by the healthcare team.

A. An expected side effect of the medication B. An allergic reaction to the nitroglycerin C. A sign that the medication should not be used again D. An indication of worsening cardiac condition

Correct Answer is A

Explanation

Choice A reason: A headache is a common and expected side effect of nitroglycerin. Nitroglycerin causes vasodilation, which can lead to increased blood flow to the head and result in headaches. It is important to inform the client that this is a known side effect and to manage it with appropriate measures, such as taking analgesics.

Choice B reason: An allergic reaction to nitroglycerin would typically present with symptoms such as rash, itching, swelling, or difficulty breathing. A headache alone does not indicate an allergic reaction.

Choice C reason: A headache does not mean the medication should not be used again. It is a common side effect, and the benefits of nitroglycerin in relieving chest pain usually outweigh the discomfort of the headache. The nurse should educate the client on managing the headache while continuing the medication.

Choice D reason: A headache is not an indication of a worsening cardiac condition. It is a common side effect of the vasodilatory effects of nitroglycerin.

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The nurse is performing a neurological assessment on the older adult. An expected finding is that:

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Naxlex Comprehensive Predictor Exams

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

Correct Answer is D

Explanation

A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?

Correct Answer is A

Explanation

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The nurse is performing a neurological assessment on the older adult. An expected finding is that: