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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Delaying surgery in a life-threatening situation could endanger the client, so waiting for parental consent is not required under emergency circumstances.
B. The pediatrician does not have the authority to provide implied consent; this legal principle applies directly to the care team in emergency situations.
C. In emergency situations where a minor requires immediate, life-saving treatment and a parent or legal guardian is not available, implied consent allows the surgeon to proceed with necessary interventions to prevent harm.
D. An adult cousin does not have legal authority to provide consent for a minor’s treatment unless specifically designated as a legal guardian.

A. Wear protective eyewear. B. Wear a mask when changing the dressing. C. Use dedicated equipment for this client. D. Turn on the HEPA filtration system.

Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

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A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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