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.

Answer and Explanation

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. .

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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.

A. Limit fluid intake to 1L each day. B. Keep a food diary to identify triggers. C. Plan three moderate to large meals per day. D. Consume 12 to 20g of fiber daily.

Correct Answer is B

Explanation

Choice A rationale

Limiting fluid intake to 1L each day is generally not recommended for individuals with irritable bowel syndrome (IBS) unless specifically indicated due to other co-existing conditions. Adequate hydration is important for overall health and can help prevent constipation, a common symptom of IBS. General recommendations for fluid intake are around 2-3 liters per day, depending on individual needs and activity levels.

Choice B rationale

Keeping a food diary is a valuable strategy for individuals with irritable bowel syndrome (IBS) to identify specific food triggers that exacerbate their symptoms such as abdominal pain, bloating, diarrhea, or constipation. By meticulously recording food intake and associated symptoms, patients can often discern patterns and work with healthcare providers to develop an individualized dietary management plan.

Choice C rationale

Planning three moderate to large meals per day might not be suitable for all individuals with irritable bowel syndrome (IBS). Some people with IBS find that smaller, more frequent meals are better tolerated as large meals can distend the bowel and trigger symptoms. Individual responses to meal size and frequency can vary significantly.

Choice D rationale

While fiber is generally beneficial for bowel regularity, a blanket recommendation of 12 to 20g of fiber daily might not be appropriate for all individuals with irritable bowel syndrome (IBS). For some individuals, particularly those with diarrhea-predominant IBS, increasing fiber intake too quickly or consuming certain types of high-fiber foods can worsen their symptoms. Fiber intake should be individualized and often increased gradually.

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Which finding for a 77-year-old patient seen in the outpatient clinic requires further nursing assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pruritus following treatment for scabies.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is completing discharge teaching with a patient who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest.The lesion is raised and flesh-colored with pearly white borders.The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

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