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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

A. Removing gloves before leaving an isolation room B. Filling a basin with water at 40° C (104° F) when providing foot care C. Instructing a client to look down at their feet when being assisted to ambulate D. Applying water-soluble lubricant to the nares of a client who is receiving oxygen

Correct Answer is B

Explanation

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.
B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.

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A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?

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