Practice Question
The nurse is assessing an older adult during a head-to-toe exam. Which finding requires immediate intervention?
Answer Choices:
Correct Answer:
New-onset facial asymmetry
Rationale:
🔷 New-onset facial asymmetry in an older adult is a neurologic red flag and can indicate acute stroke or facial nerve palsy (e.g., Bell’s palsy).
🔷 Any sudden change in facial symmetry, smile, eyelid closure, or mouth drooping must be treated as a possible cerebrovascular event until ruled out.
🔷 Stroke management is time sensitive (“time is brain”), so this finding requires immediate assessment and provider notification.
🔷 Early intervention can reduce the risk of permanent neurologic damage, disability, or death.
🔷 Because it may be part of a broader set of stroke symptoms (e.g., weakness, speech changes), it takes priority over other chronic or age-related findings.
Decreased saliva production
🔷 Decreased saliva production (xerostomia) is a common age-related change and may also be related to medications such as antihypertensives, antidepressants, or diuretics.
🔷 While it can cause difficulty swallowing, dental problems, and taste changes, it is not typically an emergency.
🔷 It should be addressed with hydration, saliva substitutes, sugar-free gum, and dental care, but it does not require immediate intervention like a possible stroke does.
🔷 This finding affects comfort and nutrition, but it is usually chronic and gradual, not a sudden dangerous change.
🔷 It is important, but not the most urgent priority compared with new neurologic deficits.
Thickened toenails
🔷 Thickened or brittle toenails are very common in older adults due to aging, decreased circulation, diabetes, or fungal infections.
🔷 Although they need podiatry care and foot assessment, especially in someone with diabetes, they are not an immediate life-threatening issue.
🔷 This finding can increase the risk of ingrown nails, skin breakdown, and infection, but these complications develop gradually.
🔷 The nurse should plan ongoing foot care, safe nail trimming, and regular inspection, particularly for those with neuropathy.
🔷 It requires follow-up, but not the same urgent response as a potential stroke.
Presbycusis
🔷 Presbycusis is age-related high-frequency hearing loss, and it is extremely common in older adults.
🔷 It can impact communication, socialization, and safety, but it is a gradual, chronic change, not an acute emergency.
🔷 Nursing interventions include speaking slowly, facing the client, reducing background noise, and considering hearing aids.
🔷 While important for quality of life and reducing isolation or confusion, it does not pose an immediate threat to life.
🔷 Therefore, it does not require emergent intervention, unlike sudden facial asymmetry.
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This question is from Custom Holistic Assessment Exam 3 which contains 50 questions.
More Questions from This Exam
Why is it important to assess both balance and coordination in elderly clients?
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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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A nurse is conducting a head-to-toe assessment on an older adult. During the musculoskeletal evaluation, which finding requires further investigation?
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4