While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Assess subconjunctival color for pallor

Review serum creatinine results.

No additional assessment needed.

Obtain every 2-hour blood pressure readings.

Answer and Explanation

The Correct Answer is C

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

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Correct Answer is C

Explanation

A. Firm, larger, and very tender to touch. This option describes the characteristics of engorged breasts, which typically occur a few days after birth as milk production increases and the breasts become full. Engorged breasts can feel firm, swollen, and tender to the touch due to the increased blood flow and milk accumulation. However, on the first postpartum day, engorgement may not yet be fully developed.

B. Soft, with no change from before delivery. This option is unlikely as the breasts typically undergo changes during the postpartum period, especially with the initiation of lactation. Soft breasts with no change from before delivery would not be expected on the first postpartum day.

C. Filling and secreting colostrum. This option is the most likely finding on the first postpartum day. Colostrum, the early milk produced by the breasts, begins to be secreted during the late stages of pregnancy and continues after birth. On the first postpartum day, the breasts may be filling with colostrum, which is typically thicker and more concentrated than mature breast milk. It is produced in small amounts, about 40-50ml on the first day but that is all an infant normally needs at this time.

D. Slightly firm with immediate let-down response. While some firmness may be present due to the initiation of lactation, an immediate let-down response is less likely on the first postpartum day. The let-down reflex, which triggers the release of milk from the breast, may take some time to establish and may not occur immediately after delivery.

A. Plan to measure the blood pressure in four hours as prescribed. B. Repeat the client's blood pressure measurement in fifteen minutes. C. Obtain an automatic blood pressure machine for hourly readings. D. Reassess the blood pressure if the client reports other symptoms.

Correct Answer is B

Explanation

A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.

B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.

C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.

D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone

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While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

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Explanation

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Explanation

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