Nokea
The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change:
- A. Moist skin
- B. Increased nail growth
- C. Dry, itchy skin
- D. Increased skin pigmentation
Correct Answer: C
Rationale: Dry, itchy skin is a normal age-related change due to decreased oil production and skin thinning.
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The nurse documents the presence of a skin lesion as a 'palpable solid mass measured at 1 cm.' What types of skin lesions might this describe? Select all that apply.
- A. Macule
- B. Patch
- C. Plaque
- D. Nodule
- E. Bulla
- F. Pustule
Correct Answer: C, D
Rationale: A palpable solid mass of 1 cm could be a plaque (elevated, >1 cm) or nodule (solid, deeper, 0.5-2 cm). Macules and patches are flat, bullae are fluid-filled, and pustules contain pus.
The nurse works with elderly clients. The nurse should recognize which of the following are physical changes associated with the aging client? Select all that apply.
- A. Pronounced wrinkles on the face
- B. Decreased size of the nose and ears
- C. Increased growth of facial hair
- D. Neck wrinkles
- E. Increased height
Correct Answer: A, C, D
Rationale: Aging causes pronounced wrinkles on the face and neck and increased facial hair due to hormonal changes. Nose and ears enlarge, and height decreases due to spinal compression.
The nurse recognizes that rewarming a client with hypothermia must be done slowly to prevent
- A. Superficial burns
- B. ventricular fibrillation
- C. frostbite
- D. muscle spasms
Correct Answer: B
Rationale: Rapid rewarming can cause ventricular fibrillation due to sudden changes in core temperature affecting cardiac rhythm. Slow rewarming helps stabilize the cardiovascular system.
Place the following actions in the order in which they need to be performed, starting with the highest priority action.
- A. Initiate a large-bore peripheral vascular access device
- B. Perform a respiratory assessment and inspect the client's nose and mouth
- C. Administer prescribed intravenous (IV) pain medication
- D. Administer prescribed intravenous (IV) fluids
- E. Perform wound care to the affected area(s)
Correct Answer: B, A, D, C, E
Rationale: Respiratory assessment is first to ensure airway patency, followed by IV access and fluids for resuscitation, pain medication for comfort, and wound care last.
Which of the following would the nurse recognize as an accurate statement regarding pressure ulcers? Select all that apply.
- A. In a stage Il pressure ulcer, part of the dermis and epidermis are lost.'
- B. In a stage I pressure ulcer, there is a loss of integrity of the epidermis only.'
- C. In a stage Ill pressure ulcer, a deep tissue injury can expose fat.'
- D. In a stage IV pressure ulcer, the base of the wound is covered by eschar.'
- E. Stage Ill involves extensive tissue damage and can lead to bone and muscle involvement.'
Correct Answer: A, C
Rationale: Stage II involves partial loss of dermis and epidermis, and Stage III can expose fat. Stage I is non-blanchable redness, Stage IV may expose bone/muscle, and eschar is not always present.