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The nurse is conducting an assessment on an older adult retired farmer. Which skin lesion should the nurse expect to see?

A.

Atopic dermatitis.

B.

Lentigines.

C.

Tinea capitis.

D.

Impetigo.

Answer and Explanation

The Correct Answer is B

A. Atopic dermatitis is a chronic inflammatory skin condition that typically begins in childhood and may persist into adulthood. While older adults can have eczema, it is not an expected finding due to normal aging and is less common in this population, especially in someone without a prior history.

B. Lentigines, also called age spots or liver spots, are flat, brown macules that develop on sun-exposed areas of the skin, such as the face, hands, and forearms. Older adults with a history of extensive sun exposure, such as a retired farmer, are particularly prone to developing lentigines due to cumulative ultraviolet (UV) damage over the years. These lesions are benign and a normal finding in aging skin.

C. Tinea capitis is a fungal infection of the scalp most commonly seen in children. It is rare in older adults, and its presence would be considered abnormal rather than an expected age-related change.

D. Impetigo is a superficial bacterial skin infection, most frequently seen in young children or in individuals with poor hygiene or immunocompromise. It is not an expected lesion in healthy older adults and would indicate an acute pathological process rather than a normal aging change.


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Related Questions

Correct Answer is ["B","C","D"]

Explanation

Rationale for correct choices:

  • There is maternal quantitative blood loss of 1,100 mL: In a vaginal delivery, a blood loss exceeding 500 mL is the clinical definition of a Postpartum Hemorrhage (PPH). A loss of 1,100 mL is over double that threshold and indicates maternal hemodynamic instability, requiring immediate intervention (such as fundal massage and uterotonics).
  • Apgar scores are 3/4/7: Apgar scores below 7 at the 1-minute and 5-minute marks (3 and 4 in this case) indicate that the newborn is having difficulty transitioning to extrauterine life and requires active resuscitation. While the score improved to 7 by 10 minutes, the initial profound depression indicates instability.
  • The newborn's oxygen saturation is 84%: While neonatal oxygen saturation starts low and rises after birth, a saturation of 84% at the time of the neonatal team's assessment (following a 10-minute Apgar) is below the expected target (typically >90% by 10 minutes of age), indicating respiratory or circulatory compromise.

Rationale for incorrect answers:

  • Second-degree perineal laceration repaired under local anesthesia: This is a common occurrence in vacuum-assisted deliveries and, once repaired, does not inherently signify instability.
  • Caput succedaneum and acrocyanosis are noted: These are expected findings. Caput (swelling of the scalp) is common after vacuum-assisted births, and acrocyanosis (bluish hands/feet) is a normal finding in newborns during the first 24–48 hours of life.

Correct Answer is C

Explanation

A. Initiating seizure precautions is not indicated based on the described posturing. The client’s abnormal response to painful stimuli reflects severe neurological impairment rather than seizure activity.

B. Administering a PRN analgesic is inappropriate because the observed posturing is a neurological sign, not a pain-related behavior. Giving analgesics will not address the underlying issue.

C. Reporting the finding to the healthcare provider is the correct action. The described response—pulling the arms inward with flexion at the elbows and wrists and extending the legs with downward-pointed toes—is decorticate (arms flexed) and decerebrate (arms extended) posturing, which indicates severe brain injury or damage to the brainstem. This is a critical, time-sensitive neurological finding that requires immediate evaluation and intervention by the healthcare provider.

D. Documenting the purposeful response to pain is incorrect. The response described is not purposeful; it is abnormal posturing indicating severe neurologic compromise. Accurate documentation is important, but the urgent priority is to notify the provider.

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