The nurse is assessing older clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

Diminished short term memory over the past year.

Reduced fine motor skills.

A negative Babinski reflex.

A change in awareness of surroundings.

Answer and Explanation

The Correct Answer is D

A.   Diminished short-term memory in older adults can be a sign of normal aging or early cognitive decline, such as mild cognitive impairment or early-stage dementia. While this is concerning, it is not typically an immediate indicator requiring urgent medical follow-up. It is important to monitor and assess memory changes over time, but it might not necessitate immediate action unless accompanied by other significant symptoms.
B.   Reduced fine motor skills can occur due to aging, arthritis, or neurological conditions such as Parkinson's disease. While this finding is important for evaluating the client's functional status and quality of life, it does not usually require immediate medical follow-up unless it is sudden, severe, or accompanied by other alarming symptoms.

C.   The Babinski reflex is a neurological test where stroking the sole of the foot causes the big toe to extend. In adults, a negative Babinski reflex (where the big toe does not extend) is normal and indicates that the corticospinal tract is functioning properly. A positive Babinski reflex is abnormal in adults and may indicate neurological damage.
D.   A change in awareness of surroundings is a more urgent concern. It could indicate acute cognitive changes, delirium, or severe neurological issues that require prompt evaluation. Such changes can be related to various serious conditions, including infections, metabolic imbalances, or acute brain disorders.

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Correct Answer is D

Explanation

A. A history of seasonal allergies and nasal congestion can affect sleep quality due to discomfort or breathing difficulties. While this information is relevant for identifying possible physical factors that might influence sleep, it is not the first piece of data to obtain when trying to understand the overall sleep pattern.
B. The consumption of caffeinated drinks before bedtime can significantly impact sleep quality. Caffeine is a stimulant that can disrupt sleep patterns and contribute to difficulty falling asleep. This assessment is important, but it should follow an initial understanding of the client’s overall sleep schedule and habits to determine how much caffeine might be affecting their sleep.
C. Urinary frequency and nocturia (waking up frequently to urinate during the night) can interfere with sleep and contribute to disturbances. This information is valuable for identifying potential causes of disrupted sleep but is typically assessed after understanding the client’s basic sleep patterns and schedule.
D. Understanding the client’s usual bedtime and time of awakenings provides essential information about their sleep schedule and overall sleep patterns. This data is crucial as it establishes a baseline for assessing the client’s sleep routine and helps identify any deviations or irregularities in their sleep behavior.

A. Intermittent pain on deep inspiration. B. An audible abdominal bruit. C. A bulge over umbilicus when coughing. D. Hypoactive bowel sounds in all quadrants.

Correct Answer is B

Explanation

A. Intermittent pain on deep inspiration could suggest pleuritic pain, which is related to the lungs or pleura rather than the abdomen. While this might be significant, it is less directly related to the client’s deep abdominal pain radiating to the back. This finding may be less urgent compared to other potential signs of serious abdominal pathology.

B. An abdominal bruit is a sound heard over the abdomen due to turbulent blood flow, often associated with vascular abnormalities like aneurysms or significant arterial stenosis. An audible abdominal bruit, especially if associated with deep abdominal pain, could indicate a serious vascular condition such as an abdominal aortic aneurysm (AAA).
C. A bulge over the umbilicus when coughing could indicate an umbilical hernia. While a hernia can be problematic and may require treatment, it is generally less urgent compared to findings that might suggest more acute or severe conditions like vascular issues.
D. Hypoactive bowel sounds can indicate decreased gastrointestinal activity, which might be related to various conditions such as ileus or bowel obstruction. While this finding is significant and warrants attention, it is often less immediately critical compared to signs of serious vascular issues or acute abdominal pathology.

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The nurse is assessing older clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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