Dif cognitive level applying application ref p 640

DIF: Cognitive Level: Applying (Application) REF: p. 640
MSC: Client Needs: Health Promotion and Maintenance
13.
During an assessment of an 80-year-old patient, the nurse notices the
following: an inability to identify vibrations at her ankle and to identify the position of
her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation.
All other neurologic findings are normal. The nurse should interpret that these findings
indicate:
a. CN dysfunction.
b. Lesion in the cerebral cortex.
c. Normal changes attributable to aging.
d. Demyelination of nerves attributable to a
lesion.
ANS: C
Some aging adults show a slower response to requests, especially for those calling for
coordination of movements. The findings listed are normal in the absence of other
significant abnormal findings. The other responses are incorrect.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 640
MSC: Client Needs: Health Promotion and Maintenance
14.
A 70-year-old woman tells the nurse that every time she gets up in the
morning or after she’s been sitting, she gets “really dizzy” and feels like she is going to
fall over. The nurse’s best response would be:
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 640
MSC: Client Needs: Health Promotion and Maintenance
15.
During the taking of the health history, a patient tells the nurse that “it
feels like the room is spinning around me.” The nurse would document this finding as: