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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Offer the child bubbles before the stethoscope is placed. Blowing bubbles can help distract the child and make them more relaxed, but it may not be as effective as involving the child directly in the process.
B. Allow the child to use a stethoscope on a stuffed animal. This is an effective approach as it involves the child in the process, making them more comfortable and cooperative. It helps demystify the stethoscope and can reduce fear or anxiety.
C. Place a toy in the child's hands while listening to the breath sounds. Holding a toy can be distracting and help keep the child still, but it does not directly involve the child in the assessment process as effectively as letting them use the stethoscope.
D. Have the child blow a cotton ball and have the parent catch it. Blowing a cotton ball can help with deep breathing, which is useful for lung auscultation. However, it may not ensure the child's cooperation throughout the entire assessment as effectively as option B.
Correct Answer is C
Explanation
A. Diminished appetite: While this can be a symptom of various conditions, it's not a direct indicator for a bone density screening.
B. Lower body mass index (BMI): A lower BMI can increase the risk of osteoporosis, but it's not a definitive sign requiring immediate bone density screening.
C. Decreased height: Losing height as an adult can be a sign of vertebral fractures caused by osteoporosis. This is a significant finding that warrants a bone density screening to assess bone mineral density.
D. 15-pound weight loss: Sudden or unexplained weight loss can be a concern, but it doesn't directly suggest the need for a bone density test unless accompanied by other risk factors.
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