A nurse at a provider's office is collecting physical data from an older adult client. Which of the following images should the nurse identify as an example of an expected age-related change?
A
B
C
D
The Correct Answer is D
A. Close-up of eyes with yellow sclera: Could indicate jaundice or liver dysfunction, which is not an expected part of aging and requires further evaluation.
B. Older adult man with a rounded back and head tilted forward: Suggests kyphosis, which can occur with aging but is usually linked to osteoporosis or vertebral fractures, not considered an inevitable, expected change.
C. Close-up of nose with a reddish-purple spot (possible bruise): Might result from trauma, coagulopathy, or medication side effects like anticoagulants, not a routine age-related change.
D. Hands with prominent veins, thin skin, and wrinkles: Thinning skin due to decreased subcutaneous fat. Wrinkles from reduced skin elasticity. Prominent veins due to loss of skin turgor and connective tissue. These are all normal physical findings in older adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Put on a gown: The gown is applied first to prevent contamination of the nurse’s clothing and skin. It acts as the foundational barrier and should be secured at the neck and waist to ensure full coverage before other PPE is donned.
B. Don a mask: The mask is put on second to protect the respiratory tract from airborne or droplet contaminants. Proper placement over the nose and mouth is essential before entering the client’s room to reduce inhalation of infectious particles.
C. Put on goggles: Goggles or a face shield are worn next to shield the eyes from splashes or sprays of infectious material. Since the eyes are a mucous membrane, they must be protected after covering the mouth and nose.
D. Don gloves: Gloves are put on last and should cover the cuffs of the gown to ensure a complete barrier. This final step helps prevent the transmission of pathogens via the hands when interacting with the client or the environment.
Correct Answer is ["A","B","F"]
Explanation
A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.
B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.
C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.
D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.
E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.
F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.
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