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Question

Difficulty: MediumAging Process

A practical nurse is evaluating an 82-year-old client at a community wellness center. Which observation should the nurse interpret as an expected physiological change related to the aging process?

  1. A
    Recent onset of disorientation and difficulty maintaining attention during the interview
  2. B
    A resting respiratory rate of 26 breaths per minute with mild use of accessory muscles
  3. Prolonged time required for the eyes to adjust when moving from a brightly lit to a dark roomAnswer
  4. D
    A resting heart rate of 108 beats per minute accompanied by slight dizziness upon standing

Answer

The observation of prolonged time required for the eyes to adjust when moving from a brightly lit to a dark room is an expected physiological change related to the aging process.
As part of the normal aging process, the pupil of the eye becomes smaller and the sphincter muscles of the iris become more rigid. This results in a slower pupillary response, meaning it takes a prolonged amount of time for the eyes to adjust when transitioning between bright and dark environments. This is a universally expected physiological change that primarily requires practical safety measures.

Step-by-Step Solution

1
Analyze the question stem to identify the primary goal.
The nurse must differentiate a normal, expected age-related physiological change from signs of acute illness or pathology.
Recognizing expected baseline changes is essential to prevent unnecessary interventions and to accurately identify true clinical deterioration.
2
Evaluate the visual change option.
Pupillary response slows with advanced age due to changes in the iris and pupil size, leading to slower accommodation to changes in lighting. This is an expected, benign finding.
This structural change requires safety education (e.g., adequate lighting, fall prevention) but no acute medical intervention.
3
Evaluate the cognitive and vital sign options for pathology.
Recent disorientation indicates acute delirium. Tachypnea with accessory muscle use indicates respiratory distress. Tachycardia with dizziness indicates potential shock or cardiovascular instability.
These findings are all abnormal at any age and require prompt escalation and medical treatment.

Key Concept

Differentiating normal physiological changes of aging from signs of acute pathology
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Topics

Aging Process

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