While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?
Apply lubricating lotion to the areas.
Refer the client for a skin lesion biopsy.
Ask about recent international travel.
Record the presence of senile lentigines.
The Correct Answer is D
A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.
B. Peripheral edema is not commonly linked to phenytoin use.
C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.
D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.
Correct Answer is D
Explanation
A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.
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