The nurse assesses the skin of a resident in the assisted-living facility and determines that which of the following is a normal physiological change related to aging?
1. Jaundiced skin color
2. Cyanotic undertones to skin color
3. Appearance of brown pigmentation on the hands
4. Plaque formations on the elbows and knees
1
Rationale: As part of the aging process, lentigo senilis, or brown spots—often referred to as age spots—can appear on the client's exposed parts, such as the hands, face, and arms. Jaundice and cyanosis are abnormal findings requiring further assessment, and should be reported to the provider. Plaque formation on the elbows could indicate the presence of psoriasis.
You might also like to view...
The nurse is reviewing prenatal charts. A client at 24 weeks has a history of class II heart disease secondary to rheumatic fever. What would the nurse expect to see in the chart?
1. Dyspnea and chest pain with mild exertion. 2. Elective cesarean birth scheduled for 37 weeks. 3. Discussed need for labor epidural and vacuum extraction. 4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally.
The nurse explains that severe preeclampsia needs to be controlled because it can develop into another syndrome called _________________
ANS:
Which of the following statements made by a nurse shows the most informed knowledge regarding the positioning of the head of a client being monitored for increasing intracranial pressure (ICP) related to a brain injury that is not vascular in nature
? 1. "The client's intracranial pressure dictates how high I position the head of the bed.". 2. "I am careful to elevate the head of the client's bed to 30 degrees.". 3. "The most controllable factor in managing intracranial pressure (ICP) is head elevation.". 4. "I elevate the client's head when the intracranial pressure is increasing.".
A nurse who was trained in an acute care setting decides to practice as a home care nurse. Which of the following statements describes one of the major differences between providing client care in the acute care and home care setting?
A) In the home setting, the nurse is in charge of the environment. B) There is more family involvement in the home care setting. C) The hospital environment calls for more flexibility on the nurse's part. D) Hospital nurses provide direct services or supervise those services to assist with activities of daily living (ADLs).