Practice Question
A nurse is conducting a head-to-toe assessment on an older adult. During the musculoskeletal evaluation, which finding requires further investigation?
Answer Choices:
Correct Answer:
Significant height loss since the last assessment.
Rationale:
🟢 Significant height loss over time in an older adult is concerning for vertebral compression fractures, osteoporosis, or spinal deformities (like kyphosis).
🟢 These conditions can lead to chronic pain, impaired mobility, decreased lung expansion, and increased fracture risk.
🟢 Height loss is not just a cosmetic change; it can reflect structural bone weakness and vertebral collapse.
🟢 This client should be evaluated further for osteoporosis, bone density status, and potential fractures, and may need treatment or fall-prevention strategies.
🟢 Because it signals a potential pathologic process, it warrants further investigation rather than being accepted as a normal aging change.
Mild difficulty with balance during toe walking
🟢 Toe walking (or walking on tiptoes) is a challenging balance task, especially for older adults with mild muscle weakness or age-related balance decline.
🟢 Mild difficulty with this advanced maneuver may reflect expected age-related changes or slight deconditioning.
🟢 It still indicates a need for fall risk assessment and possible strengthening exercises, but alone it is not as concerning as structural changes of the spine.
🟢 It is more of a functional limitation than a clear red-flag pathologic sign.
🟢 Therefore, while important to note, it is less urgent for investigation than significant height loss.
Slight tremor in the hands during rapid alternating movements
🟢 A slight tremor in the hands with rapid alternating movements can be seen in normal aging, anxiety, fatigue, or benign essential tremor.
🟢 It may indicate mild coordination difficulty, but the word “slight” suggests it is not severely impairing function.
🟢 Without other neurologic signs (rigidity, bradykinesia, resting tremor), it is less concerning than a dramatic structural skeletal change.
🟢 It should be monitored and documented, especially if it worsens or affects ADLs, but does not demand immediate workup.
🟢 Thus, it does not rise to the level of “requires further investigation” as strongly as significant height loss.
Decreased range of motion in the knees
🟢 Decreased knee ROM is very common in older adults due to osteoarthritis, joint degeneration, and reduced activity.
🟢 It can cause pain and functional limitations, but it is generally considered an expected musculoskeletal finding in aging.
🟢 Management focuses on exercise, pain control, weight management, and joint protection, but it is not necessarily a new or alarming change.
🟢 Unless the decreased ROM is sudden, very severe, or associated with trauma or infection, it is not the most concerning of the findings listed.
🟢 Therefore, compared to significant height loss, decreased ROM in the knees is more expected and less urgently investigational.
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This question is from Custom Holistic Assessment Exam 3 which contains 50 questions.
More Questions from This Exam
The nurse is assessing an older adult during a head-to-toe exam. Which finding requires immediate intervention?
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When assessing the musculoskeletal system of an aging adult, which finding is unexpected and should be reported?
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The nurse assessing the abdomen of an older adult notes distention and reports of chronic constipation. Which unexpected finding would require immediate provider notification?
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4