A nurse is performing a musculoskeletal assessment on an older adult. What normal Physiological changes of aging does the nurse expect?

Select all that apply.

Arthritis

Widened Gait

Kyphosis

Slowed movement.

Muscle atrophy

Answer and Explanation

Correct Answer : B,C,D,E,F

The normal physiological changes of aging that the nurse can expect in an older adult during a musculoskeletal assessment include:

● Widened Gait: With age, there can be a natural widening of the gait due to changes in balance and stability.

● Kyphosis: Kyphosis refers to an increased curvature of the thoracic spine, commonly known as a "hunchback" appearance, which can occur due to changes in the vertebral bones and intervertebral discs.

● Slowed movement: Older adults may experience a natural decline in their movement speed due to changes in muscle strength, coordination, and reaction time. ● Muscle atrophy: Age-related muscle atrophy, or loss of muscle mass, can occur, particularly if the older adult leads a sedentary lifestyle or has other underlying health conditions.

● Decreased joint ROM (Range of Motion): Older adults may experience a gradual decrease in joint flexibility and range of motion due to changes in the joints, ligaments, and surrounding tissues. This can affect their ability to move joints fully.

It's important to note that while some older adults may develop arthritis, it is not considered a normal physiological change of aging. Arthritis refers to the inflammation and degeneration of joints, which can occur due to various factors, including age, genetics, and lifestyle.

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Correct Answer is B

Explanation

An increased serum potassium level, also known as hyperkalemia, can have adverse effects on the electrical conduction of the heart, potentially leading to life-threatening cardiac dysrhythmias. Therefore, it is crucial to assess the patient's pulse rate and rhythm promptly to identify any abnormal cardiac activity.

Assessing the oxygen saturation (oxygen stats), respiratory rate and depth, and deep tendon reflexes are also important assessments, but they are not the priority in this case. Hyperkalemia primarily affects cardiac function, and prompt identification of any potential cardiac rhythm disturbances is essential to prevent further harm.

A. Teach the patient to pursed lip breath. B. Auscultate breath sounds every 4 hours. C. Assist the patient to get out of bed. D. Plan patient activities to minimize exertion.

Correct Answer is C

Explanation

Assisting the patient to get out of bed is a task that can be safely delegated to UAP, as long as the patient's mobility and transfer status allow for assistance without the need for specialized nursing skills. UAPs are trained to provide basic patient care, including assisting with activities of daily living, under the supervision and direction of licensed healthcare professionals.

Teaching the patient to purse lip breath requires knowledge and understanding of the technique, as well as the ability to assess the patient's response and provide feedback. This is best done by a licensed healthcare professional, such as a nurse or respiratory therapist. Auscultating breath sounds every 4 hours requires the ability to correctly use a stethoscope and interpret the findings. This task falls within the scope of practice of a nurse or respiratory therapist who has received appropriate training.

Planning patient activities to minimize exertion requires knowledge of the patient's condition, limitations, and goals. It involves assessment, evaluation, and coordination of care, which are typically performed by licensed healthcare professionals.

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A nurse is performing a musculoskeletal assessment on an older adult. What normal Physiological changes of aging does the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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