While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Assess subconjunctival color for pallor

Review serum creatinine results.

No additional assessment needed.

Obtain every 2-hour blood pressure readings.

Answer and Explanation

The Correct Answer is C

A. Assess subconjunctival colour for pallor. Subconjunctival colour assessment is not directly related to hyperpigmented freckles and is not typically indicated in this scenario.

B. Review serum creatinine results. Serum creatinine levels are not directly related to hyperpigmented freckles unless there are specific concerns about kidney function, which are not mentioned in the scenario.

C. No additional assessment needed. Hyperpigmented freckles are common benign skin findings in older adults and do not typically require further assessment unless there are other concerning symptoms or lesions present.

D. Obtain every 2-hour blood pressure readings. Blood pressure monitoring at such frequent intervals is not indicated based solely on the presence of hyperpigmented freckles.

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Correct Answer is C

Explanation

A. Teach the client to rotate the meal plate to visualize all the food on the plate: While this intervention may be helpful for other reasons, it does not directly address the client’s difficulty walking in a straight line.

B. Instruct the client to lift the left extremities with the right hand when transferring: This intervention helps with weight-bearing and balance during transfers. It compensates for the left hemiplegia and promotes stability.

C. Implement precautions when the client is judging distances during transfers: This is crucial. Clients with hemiplegia may have impaired spatial awareness and difficulty judging distances. Strategies like using a gait belt, providing cues, or ensuring a clear path can help prevent falls. Implementing precautions during transfers helps prevent falls.

D. Encourage the client to touch, wash, look at, and dress the affected side first: While this approach promotes independence, it does not directly address the client’s gait instability.

A. Longitudinal pigmented bands and red brown linear streaks of recent onset. B. Thinned depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. C. Transverse furrows and nail plate white spots that move forward with nail growth. D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally.

Correct Answer is D

Explanation

A. Longitudinal pigmented bands and red-brown linear streaks of recent onset. This description is more indicative of longitudinal melanonychia, which presents as pigmented bands along the length of the nail plate. It's not typically associated with finger clubbing.

B. Thinned, depressed nails with lateral edges tilting up to form a concave profile and proximal subungual fungal infection. This description suggests koilonychia, also known as spoon nails, which are characterized by thin, depressed nails with lateral edges tilting up. The mention of a fungal infection points to a different condition. It doesn't align with finger clubbing.

C. Transverse furrows and nail plate white spots that move forward with nail growth. This description corresponds to Beau's lines and leukonychia, which are not associated with finger clubbing. Beau's lines are transverse furrows or depressions in the nail plate, while leukonychia manifests as white spots or lines.

D. A nail base angle greater than 180 degrees and nail plate loosened at the distal-lateral edge, progressing proximally. This description fits the characteristics of finger clubbing, where there's an increased nail base angle (greater than 180 degrees) and the nail plate is loosened at the distal-lateral edge, progressing proximally. This choice aligns with the assessment finding.

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While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

Correct Answer is C

Explanation

The nurse inspects the client's fingernails. Which differentiating characteristics are observed in this assessment finding?

Correct Answer is D

Explanation

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