Which finding for a 77-year-old patient seen in the outpatient clinic requires further nursing assessment and intervention?
Decreased right knee range of motion.
Report of left hip aching when jogging.
History of recent loss of balance and fall.
Occasional mild constipation.
The Correct Answer is C
Choice A rationale
Decreased right knee range of motion is a common finding in older adults due to age-related degenerative changes like osteoarthritis. While it warrants assessment, it does not necessarily indicate an acute issue requiring immediate intervention unless accompanied by pain, swelling, or functional limitations.
Choice B rationale
Report of left hip aching when jogging could be related to musculoskeletal issues like arthritis or muscle strain, which are not uncommon in older adults. Further assessment is needed to determine the cause and appropriate management, but it does not immediately signal a critical issue requiring urgent intervention.
Choice C rationale
A history of recent loss of balance and a fall in a 77-year-old patient is a significant finding that requires further nursing assessment and intervention. Falls in older adults can lead to serious injuries such as fractures, and a recent history suggests an underlying issue affecting stability and safety. This necessitates investigation into potential causes and implementation of fall prevention strategies.
Choice D rationale
Occasional mild constipation is a common complaint among older adults due to factors like decreased physical activity, dietary changes, and medication side effects. While it should be addressed with appropriate interventions like increased fiber and fluids, it does not typically require immediate or urgent nursing intervention unless it is severe or accompanied by other concerning symptoms. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pruritus following scabies treatment is often due to residual irritation from the mites and the inflammatory response. Mittens can prevent scratching, which can exacerbate the itching, lead to skin breakdown, and increase the risk of secondary infections.
Choice B rationale
Rubbing the affected area, even gently, can further irritate the skin and intensify the itching sensation. This can prolong discomfort and potentially cause skin damage.
Choice C rationale
Applying additional scabicide after the prescribed treatment is completed is generally not recommended and can cause skin irritation or even systemic toxicity if overused. Pruritus after treatment is usually due to the body's reaction to dead mites and their products, not ongoing infestation.
Choice D rationale
Hot showers can dry out the skin and worsen pruritus. Warm or cool showers are generally recommended for individuals experiencing itching, as they are less likely to cause further irritation.
Correct Answer is B
Explanation
Choice A rationale
Obtaining a dietary history is important in managing ulcerative colitis, as certain foods can exacerbate symptoms. However, in an acute exacerbation, the immediate priority is to address physiological instability, which electrolyte imbalances can significantly contribute to.
Choice B rationale
During an acute exacerbation of ulcerative colitis, patients can experience significant fluid and electrolyte losses due to frequent and bloody diarrhea. Reviewing electrolyte values, such as potassium, sodium, and magnesium, is the priority to identify and promptly correct any imbalances that could lead to cardiac arrhythmias or other complications. Normal ranges for serum electrolytes are: Sodium: 135-145 mEq/L, Potassium: 3.5-5.0 mEq/L, Chloride: 98-106 mEq/L, Bicarbonate: 22-26 mEq/L, Calcium: 8.5-10.5 mg/dL, Magnesium: 1.5-2.5 mEq/L.
Choice C rationale
Checking perianal skin integrity is important because frequent diarrhea can lead to skin breakdown. However, this assessment is secondary to addressing potential life-threatening electrolyte imbalances that can occur during an acute flare-up.
Choice D rationale
Addressing the patient's emotional concerns is a crucial aspect of holistic care for patients with chronic conditions like ulcerative colitis. However, in the context of an acute exacerbation, the immediate physiological needs, such as identifying and correcting electrolyte imbalances, take precedence.
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