Which neurologic finding would be considered abnormal in an 88-year-old patient?
Dizziness and problems with balance
Slow papillary response to light
Jerky eye movements
Absence of the Achilles tendon jerk
The Correct Answer is D
A. Dizziness and problems with balance
While dizziness and problems with balance can occur more frequently in older adults due to age-related changes in the vestibular system and other factors, persistent or severe dizziness or balance issues should be evaluated further as they could indicate underlying neurological or medical conditions.
B. Slow papillary response to light
This finding may be considered abnormal, especially if it represents a significant change from the individual's baseline. While age-related changes in pupil function can occur, a slow or sluggish pupillary response to light may indicate dysfunction of the oculomotor nerve or other neurological issues and should be investigated further.
C. Jerky eye movements
Jerky eye movements, such as nystagmus, can be abnormal and may indicate dysfunction of the vestibular system or other neurological conditions. While some degree of nystagmus can occur with age, persistent or severe jerky eye movements should be evaluated further.
D. Absence of the Achilles tendon jerk
This finding may also be considered abnormal. The Achilles tendon reflex, tested using the deep tendon reflex (DTR) examination, can diminish with age but should not be completely absent in the absence of specific medical conditions affecting the reflex arc or spinal cord function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL).
In this case, the ordered dose is 150 mg and the concentration is 50 mg/5 mL. Therefore, the dose in mL is:
Dose (mL) = 150 mg / (50 mg/5 mL)
Dose (mL) = 150 mg x (5 mL/50 mg)
Dose (mL) = 15 mL
The nurse should round the answer to the nearest whole number, which is 15 mL. The nurse should administer 15 mL of amantadine oral solution to the client.
Correct Answer is D
Explanation
A. Polyuria:
Polyuria, or increased urine output, is not typically associated with increased intracranial pressure. It may occur due to other factors such as diabetes insipidus or fluid administration.
B. Battle's sign:
Battle's sign refers to bruising behind the ear and is often associated with basilar skull fractures. While it can indicate a head injury, it is not a direct manifestation of increased intracranial pressure.
C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck muscles, is commonly associated with meningitis rather than increased intracranial pressure. It is a sign of meningeal irritation and inflammation rather than direct pressure within the skull.
D. Lethargy:
This is the correct answer. Lethargy, or excessive drowsiness or fatigue, can be an early manifestation of increased intracranial pressure. As pressure increases within the skull, it can lead to alterations in consciousness ranging from lethargy to coma. Monitoring the client for changes in level of consciousness, including lethargy, is important for early detection of increased intracranial pressure.
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