During a community health screening fair for older adults, the nurse observes a client who has pale, bluish feet, with sores an both lower extremities that are healing poorly. Which intervention should the nurse implement?
Refer to healthcare provider for complete evaluation.
Send client to the emergency department for treatment.
Instruct client to apply antibiotic ointment to sores.
Create a list of foods that promote wound healing.
The Correct Answer is A
A) Refer to healthcare provider for complete evaluation:
The symptoms described—pale, bluish feet, and sores with poor healing—are indicative of possible peripheral vascular disease, circulatory issues, or other serious conditions that require a thorough medical evaluation. Referring the client to a healthcare provider ensures that a comprehensive assessment can be performed to diagnose the underlying cause and develop an appropriate treatment plan.
B) Send client to the emergency department for treatment:
While the symptoms are concerning, they do not necessarily indicate an immediate emergency requiring urgent care. Referral to a healthcare provider for a complete evaluation is generally more appropriate unless the client exhibits signs of a life-threatening condition or severe infection.
C) Instruct client to apply antibiotic ointment to sores:
Applying antibiotic ointment might help with wound care but does not address the underlying issue that is causing the poor wound healing and the bluish discoloration. Without a complete evaluation, it's uncertain whether antibiotic ointment alone will be sufficient or appropriate.
D) Create a list of foods that promote wound healing:
Although nutrition is important for wound healing, addressing the underlying health issues affecting the client's circulation and skin integrity is more critical. A healthcare provider can offer comprehensive treatment that includes managing the client’s overall health condition, which may involve more than just dietary changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Provide the information for research purposes only:
Providing client information without proper authorization, even for research purposes, violates confidentiality and privacy regulations. Client information should only be shared in accordance with legal and ethical guidelines to protect patient privacy.
B) Ask the student to sign a standard waiver form:
While obtaining a waiver might be necessary for some purposes, it is not sufficient on its own for releasing personal health information. The primary requirement is to obtain written authorization from the clients whose information is being requested.
C) Obtain written authorization from clients to release the information:
The most appropriate action is to obtain written authorization from the clients before releasing any personal health information. This ensures compliance with privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA), which mandates that client information be protected and only disclosed with explicit consent.
D) Ask if permission has been obtained from the research committee:
Permission from a research committee does not substitute for individual client consent. While research committees oversee ethical aspects of research, the release of personal health information must also adhere to privacy laws and require individual client authorization.
Correct Answer is C
Explanation
A) A young person with diabetes mellitus:
While diabetes mellitus is a significant health condition that requires management, especially in cold weather, it does not necessarily indicate an immediate or heightened risk compared to other conditions. Diabetes requires proper care and monitoring, but the urgency related to exposure to freezing temperatures may not be as critical as other conditions.
B) A middle-aged person who has hypertension:
Hypertension is an important condition that requires management, but in the context of a cold weather emergency, it does not represent an immediate risk related to exposure. The middle-aged person with hypertension may need stable conditions for managing their health, but their situation is less critical in terms of immediate exposure to freezing temperatures.
C) An older person who is malnourished:
An older person who is malnourished is at a higher risk when exposed to freezing temperatures. Malnutrition can impair the body’s ability to regulate temperature and increase susceptibility to cold-related illnesses such as hypothermia. Therefore, this individual is at greater risk and most in need of shelter to protect against the dangers of extreme cold.
D) An adult who was hit by a car 3 weeks ago:
An individual who was injured in a car accident 3 weeks ago may have ongoing medical needs, but unless there are specific complications or issues directly related to cold exposure, their immediate need for shelter due to freezing temperatures is less critical compared to a malnourished older person. Ensuring warmth and protection from the cold is the primary concern for those most vulnerable to the weather conditions.
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