While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?
Apply lubricating lotion to the areas.
Refer the client for a skin lesion biopsy.
Ask about recent international travel.
Record the presence of senile lentigines.
The Correct Answer is D
Rationale:
A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.
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Correct Answer is B
Explanation
Rationale:
A. Rubber-soled slippers do not provide adequate support or stability for a client with weakness.
B. Tennis shoes with velcro offer good support, stability, and ease of use, which is important for clients with weakness or impaired mobility.
C. Leather-soled loafers may be slippery and do not provide as much support or stability.
D. Slip-on rubber shower shoes lack adequate support and can be unsafe for ambulation.
Correct Answer is A
Explanation
Rationale:
A.Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.
B.Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.
C.While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.
D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.