A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

The correct answer is: B

Choice A reason: A social worker may assist clients in many ways, including finding legal representation. However, this statement does not address the client’s concern about the cost of legal representation for advance directives. It’s important to note that while social workers can provide support, they do not eliminate the need for legal representation if the client chooses to seek it.

Choice B reason: This is the correct statement because advance directives do not require legal representation to be valid. They become legally binding when signed in front of the required witnesses. This option directly addresses the client’s concern about affording legal representation by informing them that it is not necessary for the creation of advance directives.

Choice C reason: While medical care can be initiated without advance directives, this statement does not address the client’s concern about the cost of creating advance directives. It also implies that medical care is contingent on the completion of legal documents, which is not accurate.

Choice D reason: Verbal agreements are not as legally binding as written advance directives and could lead to misunderstandings or disputes later on. It is important for the client to have a clear and documented advance directive, which does not necessarily require legal review to be valid.

The correct answer is b. Remove the device from the room.

Choice A rationale:

• Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
• Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences.
• Therefore,removing the device from the room takes precedence over reporting the defect.

Choice B rationale:

• Removing the device from the room is the most appropriate first action because it:
  • Eliminates the immediate safety hazard.
  • Prevents potential harm to the client and others.
  • Protects the device from further damage.
  • Ensures the safety of the environment.
  • Demonstrates the nurse's prioritization of patient safety.

Choice C rationale:

• Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
• However,it's not the first action because it doesn't address the immediate safety concern.
• The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.

Choice D rationale:

• Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
• However,it's not relevant to the immediate safety issue of the frayed cord.
• The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
• The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.