A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?
Ecchymoses over the buttocks and lower back
Hirsutism on the face and chest
Reduced skin elasticity over the hands and forearms
Increased macules on the arms and legs
The Correct Answer is A
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.
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Correct Answer is C
Explanation
A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.
B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.
C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.
D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.
Correct Answer is A
Explanation
A. Reviewing evidence-based literature is essential to understand best practices in shift reporting and can inform the development of effective interventions. This foundational step helps ensure that any proposed changes are supported by research and proven methods.
B. While organizing a task force can be beneficial, it should occur after understanding the current best practices, as the task force's efforts would be better guided with existing evidence.
C. Creating a new reporting process without first gathering information or reviewing best practices may result in ineffective or unnecessary changes.
D. Developing a strategy to alert nurses is important, but it should be based on informed decisions derived from literature and data analysis, which should come first.