While performing a skin assessment on an older adult, the nurse notices a number of irregular, round, brownish-colored lesions on the client's hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

Apply lubricating lotion to the areas.

Refer the client for a skin lesion biopsy.

Ask about recent international travel.

Record the presence of senile lentigines.

Answer and Explanation

The Correct Answer is D

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

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Correct Answer is C

Explanation

A. Baclofen should not be stopped abruptly as it can cause withdrawal symptoms. The client should consult their healthcare provider before using other antispasmodics.
B. Monitoring intake and output every 8 hours is not specific to baclofen administration.
C. Baclofen can cause dizziness, drowsiness, and hypotension. Advising the client to move slowly and cautiously when rising and walking helps prevent falls or injury due to these side effects.
D. While muscle strength assessment is important, it is not required every 4 hours and does not specifically address the common side effects of baclofen.

A. Assess for presence of a supernumerary breast nipple. B. Palpate for evidence of temporary gynecomastia. C. Calculate approximate age menstruation should occur. D. Use the Tanner staging to determine sexual maturity.

Correct Answer is D

Explanation

A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.
B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.
C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.
D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.

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Naxlex Comprehensive Predictor Exams

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

Correct Answer is D

Explanation

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?