A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

Increased risk for falling.

Expected results for an older adult.

Need for a walker to aid in ambulation.

Likely onset of Parkinson's disease.

Answer and Explanation

The Correct Answer is A

A.   A Tinetti balance score of 12 and a gait score of 8 are indicative of an increased risk for falls. A total score below 19 suggests significant fall risk and a need for interventions to prevent injury.
B.   While the results may reflect some age-related changes, they are lower than expected for a healthy older adult without significant mobility issues.
C.   The results suggest an increased risk for falls but do not automatically indicate a need for a walker. Further assessment of functional capacity is needed.
D.   The results do not specifically indicate Parkinson's disease, although balance and gait issues may be present in such conditions. Parkinson’s diagnosis would require additional motor and neurological assessments.

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Correct Answer is D

Explanation

A. Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B. Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C. Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D. Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

A. Imbalanced nutrition, greater than body requirements. B. Deficient fluid volume. C. Excess fluid volume. D. Imbalanced nutrition, less than body requirements.

Correct Answer is D

Explanation

A. This is not applicable in this case. A BMI of 14 kg/m² indicates severe malnutrition, not excess nutrition. The client is at risk for nutritional deficiencies, not an excess of nutrition.
B. While fluid volume might be a concern in severely malnourished clients, the primary issue in this scenario is related to nutrition rather than fluid imbalance. A low BMI suggests insufficient caloric intake.
C. Excess fluid volume is not typically associated with a low BMI. In fact, clients with a BMI this low may show signs of dehydration or fluid loss due to inadequate nutritional intake.
D. This is the most appropriate nursing diagnosis. A BMI of 14 kg/m² is indicative of severe malnutrition and the client is not meeting their nutritional needs, which could lead to further health complications.

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A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

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Naxlex Comprehensive Predictor Exams

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Correct Answer is D

Explanation

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

Correct Answer is D

Explanation

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