A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?
Ecchymoses over the buttocks and lower back
Hirsutism on the face and chest
Reduced skin elasticity over the hands and forearms
Increased macules on the arms and legs
The Correct Answer is A
A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.
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Related Questions
Correct Answer is C
Explanation
A. Placing a midstream urine sample in a specimen refrigerator is an appropriate practice and does not pose an infection control hazard.
B. Wiping a countertop with chlorhexidine solution is a correct practice following a blood spill and contributes to infection control.
C. Pouring sterile 0.9% sodium chloride irrigation solution directly onto an open pressure wound before collecting a specimen poses an infection control hazard, as it can introduce contaminants to the wound and affect the culture results.
D. Using alcohol-based antiseptic to clean hands after interacting with a client who has varicella zoster is an appropriate infection control measure and reduces the risk of spreading infection.
Correct Answer is A
Explanation
A. Morphine is classified as a Schedule II controlled substance due to its high potential for abuse and dependence, but it is accepted for medical use.
B. Schedule III substances have a lower potential for abuse than Schedule II, which does not apply to morphine.
C. Schedule I substances are considered to have no accepted medical use and a high potential for abuse, such as heroin, which does not include morphine.
D. Schedule IV substances have a lower abuse potential than Schedule III, making this classification incorrect for morphine.
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