Question

A nurse is then caring for an older adult client, which new finding(s) should prompt the nurse to call for assistance Immediately? Select all that apply.

Answer 1

Correct Answers:

Paralysis of lower facial muscles
Unilateral facial cooping

Rationale :

Paralysis of lower facial muscles :

🟥 Lower facial paralysis in an older adult is a classic warning sign of acute stroke, particularly involving the cerebral cortex.

🟥 Unlike Bell palsy, stroke-related weakness often affects the lower face while sparing the forehead.

🟥 This finding indicates possible interruption of motor pathways, requiring emergency evaluation.

🟥 Early recognition allows for rapid stroke protocols, including imaging and thrombolytic consideration.

🟥 Immediate assistance is critical to reduce permanent neurologic damage.

🟥 Unilateral facial drooping :

🟥 Sudden unilateral facial drooping is a hallmark FAST stroke sign and must never be ignored.

🟥 In older adults, this finding strongly suggests acute cerebrovascular compromise.

🟥 Time-sensitive interventions depend on early detection and rapid response.

🟥 Delays can lead to worsening ischemia and long-term disability.

🟥 Prompt action supports life-saving treatment and improved outcomes.

❌ Salivary glands not enlarged.

❌ This is a normal or non-urgent finding. It does not indicate neurologic or systemic compromise.

❌ Rhinorrhea for several days.

❌ Persistent nasal drainage suggests a benign upper respiratory issue, not an emergency.

❌ Mild pain in bilateral knees.

❌ Joint pain is common in older adults and does not signal acute neurologic danger.

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Answer 2

Correct Answers:

"l recommend using a large arm cuff to avoid a falsely high blood pressure reading."

Rationale :

🟦 Using a standard cuff on a large arm results in falsely elevated blood pressure readings.

🟦 Accurate measurement requires a cuff with a bladder width of ~40% of arm circumference.

🟦 The nurse has a responsibility to correct improper technique to ensure valid data.

🟦 Educating the UAP supports safe delegation and client accuracy.

🟦 Correct cuff selection prevents misdiagnosis and inappropriate treatment.

❌ “Take care to inflate the cuff high enough to avoid a falsely low systolic reading.”

❌ Inflation pressure does not correct cuff-size errors. The issue is cuff width, not inflation height.

❌ “I recommend using the standard-sized cuff on the forearm for a more accurate reading.”

❌ Forearm readings are less accurate and not first-line unless unavoidable.

❌ “I appreciate that you're taking vitals; however, be sure to follow the protocols.”

❌ This response is too vague and fails to correct the specific error.

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Answer 3

Correct Answers:

The client is taking a blood pressure medication and reports dizziness

Rationale :

🟪 A heart rate of 52 bpm with dizziness indicates symptomatic bradycardia.

🟪 Antihypertensive medications such as beta-blockers or calcium channel blockers commonly cause this effect.

🟪 Dizziness suggests reduced cardiac output and cerebral perfusion.

🟪 This finding requires immediate evaluation and possible medication adjustment.

🟪 Symptomatic clients always take priority over asymptomatic explanations.

❌ The client is resting before an upcoming procedure.

❌ Resting bradycardia without symptoms is often benign.

❌ The client has a history of bradycardia and is asymptomatic.

❌ Chronic, asymptomatic bradycardia does not require urgent intervention.

❌ The client is a long-distance runner.

❌ Athletic bradycardia is a normal physiologic adaptation.

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Answer 4

Correct Answers:

The client is experiencing vertigo.

Rationale :

🟢 A sensation that the room is spinning is the defining characteristic of vertigo.

🟢 Otitis media can disrupt the vestibular system of the inner ear, which is responsible for balance and spatial orientation.

🟢 When vestibular input is altered, the brain misinterprets motion, producing the illusion of spinning.

🟢 Identifying vertigo helps the nurse anticipate safety risks, including falls and gait instability.

🟢 Correct interpretation guides appropriate interventions and referrals for balance-related symptoms.

❌ The client is experiencing diplopia.

❌ Diplopia refers to double vision, not a spinning sensation. It is a visual disturbance, not vestibular.

❌ The client is experiencing tinnitus.

❌ Tinnitus is described as ringing or buzzing in the ears. It does not involve a sensation of movement.

❌ The client is experiencing syncope.

❌ Syncope involves temporary loss of consciousness. The client describes spinning, not fainting.

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Answer 5

Correct Answers:

The LPN places the finger probe on the same side as the blood pressure cuff.

Rationale :

🔵 A blood pressure cuff temporarily occludes arterial blood flow during inflation.

🔵 Placing the pulse oximeter on the same extremity can result in falsely low oxygen saturation readings.

🔵 This compromises the accuracy and reliability of the measurement.

🔵 The nurse must intervene to prevent misinterpretation of oxygenation status.

🔵 Proper technique ensures safe clinical decisions based on valid data.

❌ The LPN cleans the finger probe with an alcohol swab before applying it.

❌ Cleaning the probe is an appropriate infection-control practice. It does not interfere with accuracy.

❌ The LPN removes the client’s-colored nail polish with a nail polish remover pad.

❌ Nail polish can alter light absorption and affect readings. Removing it improves accuracy.

❌ The LPN puts the finger probe on a different finger after an initially low reading.

❌ Repositioning helps verify whether a reading is accurate or artifact-related. This is appropriate practice.

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Answer 6

Correct Answers:

Areas with pressure points

Rationale :

🟠 Clients with limited mobility are at high risk for pressure injuries due to prolonged pressure over bony prominences.

🟠 Areas such as the sacrum, heels, hips, elbows, and shoulders experience reduced blood flow when compressed.

🟠 Sustained pressure leads to tissue ischemia, cell death, and skin breakdown if not relieved.

🟠 Regular assessment of pressure points allows for early detection of redness or non-blanching skin changes.

🟠 Focusing on these areas supports preventive interventions like repositioning and pressure-relief devices.

❌ Areas with scars.

❌ Scars may have altered sensation but are not the highest-risk sites for pressure injury. Pressure, not scarring, drives breakdown.

❌ Areas with tattoos.

❌ Tattoos do not affect skin integrity or pressure tolerance. They are cosmetic and not clinically relevant here.

❌ Areas with hair growth.

❌ Hair growth does not increase pressure injury risk. It has no impact on tissue perfusion.

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Answer 7

Correct Answers:

"Do you have partially or completely blocked nares?"

Rationale :

🟣 The health history of the nose focuses on airway patency and airflow.

🟣 Asking about blocked nares helps identify congestion, obstruction, or structural abnormalities.

🟣 Nasal blockage can affect breathing, sleep, smell, and oxygenation.

🟣 This question directly assesses the functional status of the nasal passages.

🟣 Accurate nasal assessment supports early identification of respiratory issues.

❌ “Do you have any difficulty walking?”

❌ This question assesses mobility, not nasal health. It is unrelated to the nose.

❌“Do you have any difficulty hearing?”

❌ Hearing relates to the ears, not the nose. It does not assess nasal function.

❌ “Do you have any changes in your sense of taste?”

❌ Taste is primarily associated with the tongue, not nasal airflow. It is not the most relevant nose question.

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Answer 8

Correct Answers:

The pressure in the arteries when the ventricles are contracting and pushing blood forward.

Rationale :

🔵 Diastolic pressure represents the pressure in the arteries during ventricular relaxation.

🔵 This phase occurs when the heart is filling with blood between contractions.

🔵 Diastolic pressure reflects baseline arterial tone and resistance.

🔵 A reading of 90 mmHg indicates elevated resting arterial pressure.

🔵 Understanding diastolic pressure is essential for assessing cardiovascular risk.

❌ The difference between the systolic and diastolic pressures.

❌ This describes pulse pressure, not diastolic pressure. It is a calculated value.

❌ The pressure in the arteries when the ventricles are contracting and pushing blood forward.

❌ This defines systolic pressure, not diastolic. It reflects contraction, not relaxation.

❌ The pressure in the veins when the ventricles are contracting.

❌ Blood pressure readings reflect arterial, not venous pressure. Veins are not measured this way.

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Answer 9

Correct Answers:

A non-healing tongue ulcer

Rationale :

🟥 A non-healing tongue ulcer is a red flag finding, especially in clients with a history of chronic alcohol use.

🟥 Alcohol is a known risk factor for oral squamous cell carcinoma, particularly when combined with other irritants.

🟥 Ulcers that do not heal may indicate malignancy or premalignant changes rather than simple inflammation.

🟥 Early identification allows for urgent referral, biopsy, and intervention, which can be life-saving.

🟥 This finding requires immediate follow-up to rule out serious pathology.

❌ Yellowish plaque on the teeth.

❌ Plaque indicates poor oral hygiene, not an emergency condition. It does not suggest malignancy.

❌ Gingival redness.

❌ Gingival redness is commonly related to gingivitis or irritation. It is not immediately life-threatening.

❌ Dry oral mucosa.

❌ Dry mucosa suggests dehydration or medication effects. It does not require urgent intervention.

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Answer 10

Correct Answers:

Pinch up a fold of skin under the clavicle

Rationale :

🟦 Skin turgor assesses hydration status by evaluating skin elasticity.

🟦 In adults, the area under the clavicle provides the most accurate assessment because it is less affected by aging.

🟦 The nurse gently pinches the skin and observes how quickly it returns to its original position.

🟦 Delayed recoil indicates dehydration or fluid volume deficit.

🟦 Using the correct site ensures reliable and clinically meaningful findings.

❌ Squeeze together skin fold on abdomen.

❌ Abdominal skin may be affected by fat distribution or laxity. It is not the preferred site.

❌ Inspect the conjunctivae for moisture.

❌ Conjunctivae moisture assesses hydration indirectly, not skin turgor. It is a different assessment.

❌ Palpate the forearm with dorsal surface of hand.

❌ This technique assesses temperature, not turgor. It does not evaluate skin elasticity.

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QLexNursing

1 :
A nurse is then caring for an older adult client, which new finding(s) should prompt the nurse to call for assistance Immediately? Select all that apply.

2 :
The nurse notices that an unlicensed assistive personnel (UAP) is preparing to check a client's blood pressure with a large arm girth using a standard-sized blood pressure cuff. How should the nurse respond?

3 :
The nurse assesses a client with a heart rate of 52 beats per minute. Which finding should the nurse prioritize?

4 :
A client diagnosed with otitis media reports a sensation that the room is spinning. How should the nurse interpret this finding?

5 :
The nurse observes a licensed practical nurse (LPN) obtain an oxygen saturation on a client. Which action by the LPN should cause the nurse to intervene?

6 :
When assessing skin integrity, which areas should be given particular attention in clients with limited mobility?

7 :
The nurse is completing a health history of a client. Which question should the nurse ask in regards to the health history of the client's nose?

8 :
A nurse is assessing a client's blood pressure. The reading is 140/90 mmHg. What does the diastolic pressure indicate?

9 :
The nurse cares for a client with a history of alcohol use. Which finding requires immediate follow-up from the nurse?

10 :
What is the correct technique for assessing skin turgor on an adult client?

QLexNursing

1 : A nurse is then caring for an older adult client, which new finding(s) should prompt the nurse to call for assistance Immediately? Select all that apply.

2 : The nurse notices that an unlicensed assistive personnel (UAP) is preparing to check a client's blood pressure with a large arm girth using a standard-sized blood pressure cuff. How should the nurse respond?

3 : The nurse assesses a client with a heart rate of 52 beats per minute. Which finding should the nurse prioritize?

4 : A client diagnosed with otitis media reports a sensation that the room is spinning. How should the nurse interpret this finding?

5 : The nurse observes a licensed practical nurse (LPN) obtain an oxygen saturation on a client. Which action by the LPN should cause the nurse to intervene?

6 : When assessing skin integrity, which areas should be given particular attention in clients with limited mobility?

7 : The nurse is completing a health history of a client. Which question should the nurse ask in regards to the health history of the client's nose?

8 : A nurse is assessing a client's blood pressure. The reading is 140/90 mmHg. What does the diastolic pressure indicate?

9 : The nurse cares for a client with a history of alcohol use. Which finding requires immediate follow-up from the nurse?

10 : What is the correct technique for assessing skin turgor on an adult client?

1 :
A nurse is then caring for an older adult client, which new finding(s) should prompt the nurse to call for assistance Immediately? Select all that apply.

2 :
The nurse notices that an unlicensed assistive personnel (UAP) is preparing to check a client's blood pressure with a large arm girth using a standard-sized blood pressure cuff. How should the nurse respond?

3 :
The nurse assesses a client with a heart rate of 52 beats per minute. Which finding should the nurse prioritize?

4 :
A client diagnosed with otitis media reports a sensation that the room is spinning. How should the nurse interpret this finding?

5 :
The nurse observes a licensed practical nurse (LPN) obtain an oxygen saturation on a client. Which action by the LPN should cause the nurse to intervene?

6 :
When assessing skin integrity, which areas should be given particular attention in clients with limited mobility?

7 :
The nurse is completing a health history of a client. Which question should the nurse ask in regards to the health history of the client's nose?

8 :
A nurse is assessing a client's blood pressure. The reading is 140/90 mmHg. What does the diastolic pressure indicate?

9 :
The nurse cares for a client with a history of alcohol use. Which finding requires immediate follow-up from the nurse?

10 :
What is the correct technique for assessing skin turgor on an adult client?