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 B
Explanation
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
Correct Answer is D
Explanation
A. Notifying the nurse manager is important, but it is not the immediate priority when a family member has fainted.
B. Completing an incident report is necessary for documentation but should occur after addressing the immediate medical concern.
C. Obtaining the family member's health history is not pertinent at this moment as the priority is to assess their current condition.
D. Checking the family member's vital signs is the first action to determine their immediate health status and any necessary interventions to provide appropriate care.