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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.

Answer and Explanation

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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A. Determine if the client is taking an anticholinergic drug such as benztropine mesylate. B. This is an expected side effect of chlorpromazine which requires no further action. C. Call the healthcare provider and refuse to administer any more chlorpromazine. D. Decrease the dose of chlorpromazine and notify the healthcare provider.

Correct Answer is A

Explanation

Rationale:

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.

B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.

C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.

D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

A. Use a pulse oximeter to assess oxygen saturation. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Check the client's capillary glucose level.

Correct Answer is C

Explanation

Rationale:

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.

B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.

C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.

D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

Correct Answer is A

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

A client who is 12 weeks pregnant has type 1 diabetes mellitus. Which instruction should the nurse provide related to insulin dosages?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

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