Which assessment finding would be considered normal in an elderly client?

Decreased flexibility.

Pain when standing.

Swelling of the ankles.

Urinary incontinence.

Answer and Explanation

The Correct Answer is A

Decreased flexibility is a normal age- related change that occurs in the elderly due to loss of elasticity in the ligaments and tendons.
Some possible explanations for the other choices are:
Choice B. Pain when standing. Pain when standing is not a normal finding and could indicate arthritis, osteoporosis, or injury.
Choice C. Swelling of the ankles. Swelling of the ankles is not a normal finding and could indicate heart failure, kidney disease, or venous insufficiency.
Choice D. Urinary incontinence. Urinary incontinence is not a normal finding and could indicate urinary tract infection, prostate enlargement, or neurological impairment.

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Correct Answer is ["B","C","D"]

Explanation

The nurse should acknowledge the need for intimacy and value themselves in sexual relationships, ask if sexual experiences cause any kind of physical or emotional discomfort, and discuss any changes in sexual experience or satisfaction since beginning new treatments ordered by care providers.

These actions show respect, empathy, and professionalism towards the client’s sexuality.

Choice A is wrong because waiting for the client to volunteer information about any sexual problems they are having may imply that the nurse is uncomfortable or uninterested in addressing sexuality.

The nurse should initiate the conversation and create a safe and supportive environment for the client to express their concerns.

A. Decreased blood pressure. B. Increased temperature. C. Impaired physical coordination. D. Nausea and appetite loss. E. Respiratory depression.

Correct Answer is ["A","C","E"]

Explanation

Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.

Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.

Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.

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Which assessment finding would be considered normal in an elderly client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client reports altered sexuality patterns, the nurse should: (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse should include which statement when instructing a client about Transcranial Magnetic Stimulation (TMS).

Which symptom experienced by a client receiving a continuous enteral feeding via a nasogastric tube requires priority follow-up by the nurse?

A client has lorazepam prescribed before surgery and refuses the injection. If the nurse administers the scheduled injection despite the client’s lack of consent, which term best describes the nurse’s action?

The family of a client that has been diagnosed with terminal cancer decided not to inform the client of the prognosis. What is the most appropriate action for a nurse to take when the client repeatedly asks about prognosis?

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Which instruction should a nurse include in the teaching plan for a client receiving non-steroidal anti-inflammatory drugs (NSAIDS) for the treatment of rheumatoid arthritis?

A client who has a blood glucose level of 800 mg/dL is to receive insulin intravenously. Which form of insulin is safe for intravenous administration?

Which of these assessment findings should a nurse record as subjective?