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. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodic.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.
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.