A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?
A client who has dementia and is experiencing paranoia
A client who has a UTI and reports itching after receiving a dose of cefaclor PO
A client who has heart failure and has gained 1 kg (2.2 lb) in the last 48 hr
A client who has a pressure ulcer on the left heel that has progressed from stage II to stage III
The Correct Answer is D
A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.
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View Related questions
Correct Answer is A
Explanation
A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.
Correct Answer is D
Explanation
A. Using only room numbers for client identification does not guarantee confidentiality, as room numbers can still be linked to specific individuals.
B. Logging assistive personnel into unit computers compromises security and violates confidentiality protocols. Each user should have a unique login.
C. Including a client’s name on a fax cover sheet is not recommended, as it exposes protected health information and can breach confidentiality.
D. Conducting change-of-shift report in a staff-only area protects client information from being overheard by unauthorized individuals, ensuring confidentiality.