Take full exam for free

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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Prepare to administer a glucose, then insulin, then potassium infusion. B. Instruct the client to increase daily intake of potassium rich foods. C. Inform the healthcare provider of the need for potassium replacement. D. Change the plan of care to include hourly urinary output measurements. E. Change the plan of care to include hourly urinary output measurements.

Correct Answer is C

Explanation

Rationale:

A. The combination of glucose and insulin is used to shift potassium into cells, which would lower serum potassium levels further; this is not appropriate for treating hypokalemia.

B. Increasing dietary intake of potassium is important but not sufficient to correct a serum potassium level as low as 2.5 mEq/L, which requires more immediate intervention.

C. A potassium level of 2.5 mEq/L is critically low and can lead to life-threatening cardiac arrhythmias. The healthcare provider should be informed immediately to initiate potassium replacement therapy, likely via intravenous infusion.

D. Hourly urinary output measurements may be useful but are not the immediate priority in treating severe hypokalemia.

A. Rubber soled slippers. B. Tennis shoes with velcro. C. Leather soled loafers. D. Slip on rubber shower shoes.

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.

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is B

Explanation

Quick Links

Resources

Free Nursing Test Bank

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)]

Correct Answer is C

Explanation

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is B

Explanation

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

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

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?

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?

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?

A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

Quick Links

Resources