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 B
Explanation
Choice A rationale
While laboratory testing may eventually be necessary to identify the cause of diarrhea, the immediate priority is to gather more information about the patient's condition. Jumping directly to testing without understanding the symptoms could delay appropriate initial interventions and fail to address immediate needs.
Choice B rationale
Assessing the characteristics of the stools, such as frequency, consistency, color, and any associated symptoms like abdominal pain, nausea, vomiting, or fever, is crucial for determining the potential cause and severity of the diarrhea. This information guides subsequent interventions and helps differentiate between self-limiting conditions and those requiring further investigation.
Choice C rationale
Advising the use of loperamide without a proper assessment could mask underlying issues, potentially delaying appropriate treatment if the diarrhea is due to an infection or other serious condition. Antidiarrheal medications are not always indicated and should be used cautiously.
Choice D rationale
While maintaining hydration and electrolyte balance is important, especially with diarrhea, it is not the first action a nurse should take before understanding the nature of the patient's symptoms. The initial step should be to gather more information to guide appropriate advice and interventions.
Correct Answer is D
Explanation
Choice A rationale
Migraine headaches are a common comorbidity associated with fibromyalgia. Studies suggest a shared pathophysiology involving central sensitization and altered pain processing mechanisms in the central nervous system that contribute to both conditions.
Choice B rationale
Weather changes, particularly fluctuations in barometric pressure, temperature, and humidity, are frequently reported by individuals with fibromyalgia as triggers for increased pain and other symptoms like stiffness and fatigue. The exact mechanisms are not fully understood but may involve changes in tissue pressure and nerve sensitivity.
Choice C rationale
Chest pain, specifically non-cardiac chest pain, is a recognized symptom in some individuals with fibromyalgia. This pain is often musculoskeletal in origin, arising from tender points in the chest wall and surrounding muscles, and is not related to cardiac issues.
Choice D rationale
Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues. Unlike rheumatoid arthritis or osteoarthritis, fibromyalgia does not involve joint inflammation or structural damage to the joints. The pain is believed to originate from amplified pain signals in the brain and spinal cord.
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