Which neurologic finding would be considered abnormal in an 88-year-old patient?

Dizziness and problems with balance

Slow papillary response to light

Jerky eye movements

Absence of the Achilles tendon jerk

Answer and Explanation

The Correct Answer is D

A. Dizziness and problems with balance

While dizziness and problems with balance can occur more frequently in older adults due to age-related changes in the vestibular system and other factors, persistent or severe dizziness or balance issues should be evaluated further as they could indicate underlying neurological or medical conditions.

B. Slow papillary response to light

This finding may be considered abnormal, especially if it represents a significant change from the individual's baseline. While age-related changes in pupil function can occur, a slow or sluggish pupillary response to light may indicate dysfunction of the oculomotor nerve or other neurological issues and should be investigated further.

C. Jerky eye movements

Jerky eye movements, such as nystagmus, can be abnormal and may indicate dysfunction of the vestibular system or other neurological conditions. While some degree of nystagmus can occur with age, persistent or severe jerky eye movements should be evaluated further.

D. Absence of the Achilles tendon jerk

This finding may also be considered abnormal. The Achilles tendon reflex, tested using the deep tendon reflex (DTR) examination, can diminish with age but should not be completely absent in the absence of specific medical conditions affecting the reflex arc or spinal cord function.

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Correct Answer is C

Explanation

A.While monitoring for elevated blood pressure is important in identifying autonomic dysreflexia once it occurs, it does not prevent the condition. The nurse should focus on eliminating potential triggers, such as bladder distention or constipation, to prevent the occurrence.

B.Headaches are a symptom of autonomic dysreflexia, often related to severe hypertension. While treating the headache may alleviate discomfort, it does not address the underlying cause, nor does it prevent the onset of autonomic dysreflexia.

C.Bladder distention is a common trigger for autonomic dysreflexia in individuals with spinal cord injuries. The nurse should ensure that the client's bladder is regularly emptied to prevent overdistention, which can stimulate the autonomic reflex and trigger AD.

D.Elevating the head is an intervention used during an episode of autonomic dysreflexia to help lower blood pressure and reduce symptoms. However, this action does not prevent the condition from occurring.

A. Nystagmus B. Strabismus C. Blurry vision D. Amblyopia

Correct Answer is A

Explanation

A. Nystagmus:

Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.

B. Strabismus:

Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.

C. Blurry vision:

Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.

D. Amblyopia:

Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.

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Which neurologic finding would be considered abnormal in an 88-year-old patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Correct Answer is C

Explanation

Which condition would indicate to the nurse that the patient has a phenytoin (Dilantin) toxicity?

Correct Answer is A

Explanation

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Which neurologic finding would be considered abnormal in an 88-year-old patient?

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