You notice that your older adult male client frequently knocks his arm or hand against door frames or chair backs and then develops a purpura. What do you advise your client to do? (Select all that apply.)
Protect the skin from trauma.
Remind the health care personnel to be gentle when handling this client’s skin.
Wear a long-sleeved shirt.
Tape a nonadherent dressing over the site of a skin tear.
Correct Answer : A,B,D
Choice A: Protect the skin from trauma. This is a correct answer. Purpura is the discoloration of the skin or mucous membranes due to hemorrhage from small blood vessels¹. It can be caused by various factors, such as blood clotting disorders, medications, infections, or weak blood vessels². Older adults are more prone to develop purpura because their skin becomes thinner and more fragile with age³. Therefore, protecting the skin from trauma, such as knocking against hard surfaces, can help prevent or reduce purpura.
Choice B: Remind the health care personnel to be gentle when handling this client’s skin. This is also a correct answer. Health care personnel should be aware of the risk of purpura in older adults and handle their skin with care. They should avoid applying excessive pressure, friction, or shear forces to the skin, as these can cause damage to the blood vessels and result in purpura. They should also use soft and smooth materials, such as cotton or silk, when dressing or cleaning the skin.
Choice C: Wear a long-sleeved shirt. This is not a correct answer. Wearing a long-sleeved shirt may provide some protection to the skin, but it is not enough to prevent purpura. Moreover, wearing tight or rough clothing can actually worsen the condition by causing irritation or injury to the skin. Therefore, this is not a good advice for the client.
Choice D: Tape a nonadherent dressing over the site of a skin tear. This is another correct answer. A skin tear is a type of wound that occurs when the skin is separated from the underlying tissue, usually due to trauma. Skin tears are common in older adults and can lead to purpura if the blood vessels are damaged. Taping a nonadherent dressing over the site of a skin tear can help protect the wound from infection, promote healing, and prevent further bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Older adult declines company, is preoccupied with lethal weapons is the highest risk factor for suicide, as it indicates social isolation, hopelessness, and suicidal intent. The older adult may be suffering from depression, anxiety, or other mental health issues that impair their quality of life and increase their likelihood of harming themselves.
Choice B reason: Liver failure is due to alcohol abuse, older adult is popular at meals is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a chronic medical condition that affects their liver function, but they may also have a supportive social network and coping skills that reduce their risk of suicide.
Choice C reason: Refuses to allow a large, extended family to help him is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a preference for independence and autonomy, or they may have a strained relationship with their family. However, they may also have other sources of support and meaning in their life that lower their risk of suicide.
Choice D reason: The older adult had an overdose of acetaminophen 20 years ago; is in a sewing group is not the highest risk factor for suicide, as it does not indicate current suicidal ideation or behavior. The older adult may have a history of a suicide attempt, but they may also have recovered from their past crisis and found a positive outlet for their emotions and interests in the sewing group.
Choice E reason: None of the above is not the correct answer, as there is one choice that indicates the highest risk for suicide.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because baroreceptor function diminishes with age, and this can affect the regulation of blood pressure and heart rate. Baroreceptors are sensory receptors that detect changes in blood pressure and send signals to the brain to adjust the heart rate and blood vessel tone accordingly. When a person exercises, the blood pressure and heart rate increase to meet the increased oxygen demand of the muscles. When a person stops exercising, the blood pressure and heart rate should decrease gradually to return to the resting state. However, if a person does not cool down properly after exercising, the blood pressure and heart rate can drop suddenly, causing dizziness, fainting, or cardiac arrhythmias. This is especially true for older adults, whose baroreceptors are less sensitive and responsive to blood pressure changes. Therefore, the nurse should instruct the older man to cool down after exercising to prevent these complications.
Choice B reason: This is incorrect because sensory perception diminishes with age, but this is not related to the importance of cooling down after exercising. Sensory perception is the ability to perceive stimuli from the environment, such as sight, hearing, touch, smell, or taste. Sensory perception can decline with age due to various factors, such as age-related changes in the sensory organs, nerve damage, or diseases. This can affect the quality of life, communication, and safety of older adults, but it does not explain why cooling down after exercising is important.
Choice C reason: This is incorrect because cardiac output diminishes with age, but this is not related to the importance of cooling down after exercising. Cardiac output is the amount of blood pumped by the heart per minute, and it depends on the heart rate and the stroke volume. Cardiac output can decline with age due to various factors, such as age-related changes in the heart muscle, valves, or arteries, or diseases. This can affect the ability of the heart to meet the oxygen demand of the body, especially during exercise, but it does not explain why cooling down after exercising is important.
Choice D reason: This is incorrect because mobility capacity decreases with age, but this is not related to the importance of cooling down after exercising. Mobility capacity is the ability to move and perform physical activities, such as walking, climbing stairs, or lifting objects. Mobility capacity can decrease with age due to various factors, such as age-related changes in the muscles, bones, or joints, or diseases. This can affect the functional status, independence, and well-being of older adults, but it does not explain why cooling down after exercising is important.
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