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 C
Explanation
Rationale:
A. A WBC count within the normal range does not indicate an adverse effect of gentamicin.
B. Gentamicin is more likely to increase BUN levels due to nephrotoxicity rather than decrease them.
C. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, which can lead to hearing loss. Decreased hearing is a significant adverse effect that should be promptly addressed.
D. Photophobia is not a common side effect of gentamicin.
Correct Answer is B
Explanation
Rationale:
A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.
B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.
C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.
D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.