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 D
Explanation
Choice A rationale
Increasing protein intake is important for tissue repair and overall healing in patients with osteomyelitis. However, addressing the acute bacterial infection is the immediate priority to prevent further bone destruction and systemic spread of the infection.
Choice B rationale
Teaching relaxation breathing can help manage the pain associated with osteomyelitis. While pain management is crucial for patient comfort, it does not address the underlying bacterial infection that is causing the acute illness and bone damage.
Choice C rationale
Antipyretic therapy, such as acetaminophen or ibuprofen, can help reduce fever, which is a common systemic manifestation of acute osteomyelitis. However, lowering the fever does not treat the underlying infection and its potential complications.
Choice D rationale
Acute osteomyelitis is a bone infection, and the priority intervention is the prompt administration of antibiotics. Antibiotics target and eradicate the causative bacteria, preventing further bone destruction, reducing the risk of sepsis, and promoting healing. Delaying antibiotic administration can lead to severe and potentially life-threatening complications.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A client who is ambulatory following a cardiac catheterization 4 hours ago has increased mobility, which reduces the risk of prolonged pressure on bony prominences. The short duration post-procedure and ability to ambulate make this client less susceptible to pressure ulcer development.
Choice B rationale
Postoperative delirium can lead to decreased mobility, increased agitation and friction against surfaces, and impaired ability to communicate discomfort or reposition themselves. These factors significantly increase the risk of prolonged pressure and subsequent pressure ulcer formation.
Choice C rationale
Protein-calorie malnutrition results in decreased subcutaneous tissue and muscle mass, which normally provide cushioning over bony prominences. Poor nutritional status also impairs tissue repair and increases skin fragility, making the client highly susceptible to pressure ulcer development.
Choice D rationale
Right-sided heart failure can cause fluid overload and peripheral edema, particularly in the lower extremities. This edema increases tissue fragility and reduces blood flow to the skin, making it more susceptible to breakdown and pressure ulcer formation, especially in areas with bony prominences like heels and ankles.
Choice E rationale
While hyperglycemia in type 1 diabetes mellitus can impair wound healing and increase the risk of infection if a pressure ulcer develops, it is not a direct primary risk factor for the initial development of pressure ulcers. Immobility, malnutrition, and edema are more direct contributors to skin breakdown due to pressure.
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