The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up?
A) The client states that a mole on his forehead has become larger in recent months.
B) Decreased skin turgor is evident when the skin is folded and then released.
C) Small, round, red spots are present on the client's forearms bilaterally.
D) There are some raised, brown areas on the backs of the client's hands.
Ans: A
Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).
You might also like to view...
The nurse is teaching an adolescent about acne care. What statement by the adolescent indicates a need for further teaching?
a. "I will cleanse my face twice a day." b. "I will frequently shampoo my hair." c. "I will brush my hair away from my forehead." d. "I will use my antibacterial soap to cleanse my face."
The nurse is orientating a nursing assistant and is discussing handwashing principles. Which statement from the nursing assistant indicates a good understanding of those principles?
a. If my hands are visibly soiled, I cannot use an alcohol rub. b. I do not need to wash my hands if I have used gloves. c. I must always use soap and water after a dressing change. d. I can always use an alcohol rub instead of soap and water.
A 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take?
a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.
Patients should be advised not to overuse laxatives, because the smooth muscle in the colon can lose its tone. What condition should the nurse warn the client can occur if this happens?
1. Chronic constipation 2. Chronic diarrhea 3. Chronic nausea 4. Frequent vomiting