When assessing an older client as they walk into the exam room, which finding would the nurse document as abnormal?

When assessing an older client as they walk into the exam room, which finding would the nurse document as abnormal?

• A. Client is wearing an excessive amount of cologne
• B. Client introduces themselves clearly
• C. Client has a steady gait
• D. Client's hands are warm to touch

Answer: (A)

The main idea is that initial observation should identify signs that point to a possible health issue. A notable abnormal finding when an older adult enters the room is that the hands feel warm to touch. Warm hands can indicate fever or infection, which is something to document and follow up on with vital signs and further assessment. By contrast, introducing themselves clearly shows good communication, a steady gait suggestsnormal mobility, and an strong fragrance is a social/personal hygiene cue rather than a medical abnormality in the exam context. So the finding that should be documented as abnormal is hands that are warm to touch.

The main idea is that initial observation should identify signs that point to a possible health issue. A notable abnormal finding when an older adult enters the room is that the hands feel warm to touch. Warm hands can indicate fever or infection, which is something to document and follow up on with vital signs and further assessment. By contrast, introducing themselves clearly shows good communication, a steady gait suggestsnormal mobility, and an strong fragrance is a social/personal hygiene cue rather than a medical abnormality in the exam context. So the finding that should be documented as abnormal is hands that are warm to touch.