Which of the below items are expected variations in an older adult?
Head protrusions.
Asymmetry of facial features.
Thinning hair.
Vertigo.
The Correct Answer is C
Choice A reason: Head protrusions are not expected in older adults; they may indicate abnormal growths or trauma, requiring investigation. Thinning hair is a normal aging change. Assuming protrusions are expected risks missing serious conditions like tumors, delaying diagnosis and treatment critical for ensuring safety in elderly patients.
Choice B reason: Asymmetry of facial features is not a normal aging variation; it may suggest stroke or Bell’s palsy, needing urgent evaluation. Thinning hair is expected due to hormonal changes. Assuming asymmetry is normal risks overlooking neurological issues, delaying interventions critical for older adults’ health and functional outcomes.
Choice C reason: Thinning hair is an expected aging variation, resulting from reduced hair follicle activity and hormonal changes in older adults. Unlike vertigo or asymmetry, it’s benign and doesn’t require intervention unless cosmetic. Recognizing this ensures accurate assessment, focusing on abnormal findings like vertigo that need medical attention in elderly patients.
Choice D reason: Vertigo is not an expected aging variation; it may indicate inner ear disorders or neurological issues, requiring evaluation. Thinning hair is a normal change. Assuming vertigo is expected risks delaying diagnosis of treatable conditions like BPPV, compromising safety and quality of life in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Blood pressure 127/65 and HR 68 are within normal ranges (BP <130/<80, HR 60-100), expected in healthy cardiovascular assessments. Trace edema is abnormal, suggesting fluid retention. Assuming this is unexpected risks overlooking normal findings, diverting focus from issues like edema needing evaluation in cardiovascular assessments.
Choice B reason: Trace edema in bilateral lower ankles is an unexpected finding, indicating potential fluid overload, heart failure, or venous insufficiency. Unlike normal vitals or pulses, edema requires investigation and reporting. Recognizing this ensures timely diagnosis and management, critical for preventing progression of underlying cardiovascular or systemic conditions in affected patients.
Choice C reason: Capillary refill within 2 seconds is normal, indicating adequate peripheral perfusion, expected in cardiovascular assessments. Edema is the abnormal finding. Assuming refill is unexpected risks misprioritizing normal findings, neglecting issues like edema that signal potential heart or venous issues, critical for accurate cardiovascular evaluation and care.
Choice D reason: Equal apical and radial pulses are expected, reflecting synchronized cardiac output, normal in cardiovascular assessments. Trace edema is abnormal, suggesting fluid issues. Assuming pulses are unexpected risks overlooking normal findings, diverting attention from edema, critical for identifying and managing underlying cardiovascular conditions in clinical practice.
Correct Answer is C
Explanation
Choice A reason: Drainage, odor, appearance, and size provide incomplete wound documentation, missing critical details like location and depth. Comprehensive wound assessment requires precise measurements and site identification to track healing, guide treatment, and prevent complications like infection, making this choice insufficient for clinical standards.
Choice B reason: Size, odor, location, and depth omit key descriptors like appearance and drainage, which indicate infection or healing status. Wound documentation must include all measurable aspects to ensure accurate monitoring and treatment planning, rendering this choice inadequate for thorough medical records.
Choice C reason: Location, length, width, depth, appearance, and drainage form a complete wound description, capturing site, dimensions, tissue characteristics, and exudate. This comprehensive approach supports accurate tracking of healing, infection risk, and treatment efficacy, aligning with clinical guidelines for wound care documentation and management.
Choice D reason: Color, location, appearance, and drainage lack measurements like length, width, and depth, essential for monitoring wound progression. Omitting these quantifiable metrics hinders accurate assessment of healing or deterioration, making this choice incomplete for standardized wound documentation in clinical practice.
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