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 A
Explanation
A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.
Correct Answer is B
Explanation
A. While reviewing previous appraisals may provide some context, it is not the most effective way to evaluate current performance.
B. Gathering information from clients provides direct feedback about the AP’s performance and interactions, making it a valuable input for performance appraisals.
C. Examining the job description is helpful for understanding expectations, but it does not provide specific performance insights needed for an appraisal.
D. Peer reviews can be informative, but they may not reflect the full scope of the AP's duties and interactions with clients, which are critical for a comprehensive performance appraisal.