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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. 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. Maintain a cheerful and calm appearance while spending time with the client. B. Listen for changes in what the client hopes for and try to help meet the goals. C. Avoid the client having to make any decisions to help save the client's energy. D. Offer meals prepared with the client's favorite foods at frequent, regular intervals.

Correct Answer is B

Explanation

Rationale:

A. A cheerful and calm appearance may not always align with the client's emotional needs and could feel insincere.

B. As the client nears the end of life, their hopes may shift, and it is crucial for the spouse to listen and help fulfill these evolving goals to provide comfort and maintain dignity.

C. Encouraging the client to make decisions as they are able can empower them, rather than avoiding decision-making.

D. Offering favorite foods is thoughtful but does not directly address the emotional and psychological aspects of hopelessness.

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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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 home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

Correct Answer is B

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

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The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

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