A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?
Ecchymoses over the buttocks and lower back
Hirsutism on the face and chest
Reduced skin elasticity over the hands and forearms
Increased macules on the arms and legs
The Correct Answer is A
A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Logging the previous user out of the system immediately ensures the client's health information is no longer visible, protecting the client's privacy according to HIPAA guidelines.
B. Offering to conduct an in-service on client confidentiality is a proactive measure but does not address the immediate privacy issue.
C. Reporting the incident to the charge nurse is appropriate but does not prevent unauthorized viewing of the client's information immediately.
D. Completing an incident report is necessary to document the breach, but it should occur after protecting the client’s privacy by logging out.
Correct Answer is D
Explanation
A. Encouraging the expression of feelings about illness can be a part of patient-centered care, but it does not fully encompass the role of advocacy, which involves more comprehensive support for the client's needs.
B. Reinforcing teaching about prescribed medications is important but falls under education and patient care rather than advocacy itself.
C. Collaboration with other team members is essential in providing holistic care but does not solely represent advocacy, which focuses more on the client's interests.
D. Supporting the client's needs is the core of advocacy, as it involves standing up for the client's rights, preferences, and well-being within the healthcare system.
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