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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. Palpate the client's muscle tone. B. Instruct the client to close his eyes. C. Apply resistance to the client's arms. D. Give the client an object to hold.

Correct Answer is C

Explanation

Rationale:

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

A. Apply light pressure proximal to the IV site. B. Assess the radial pulse distal to the IV site. C. Assist the client to straighten the right arm. D. Elevate the client's right arm on one pillow.

Correct Answer is C

Explanation

Rationale:

A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.

B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.

C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.

D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

Correct Answer is C

Explanation

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Which client is at greatest risk for aspiration?

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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?

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?

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