Author Question: When examining an older patient in the home, the home health nurse notices irregular patterns of ... (Read 113 times)

misspop · **on:** Jun 25, 2018

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first?

a. Discourage the use of throw rugs throughout the house.
b. Ensure the patient has a pair of shoes with non-slip soles.
c. Talk with the patient alone and ask about what caused the bruising.
d. Notify the health care provider so that x-rays can be ordered as soon as possible.

Question 2

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?

a. Reports a history of allergic rashes
b. Scattered macular brown areas on extremities
c. Skin brown and wrinkled, skin tenting on forearm
d. Longitudinal nail bed ridges noted; sparse scalp hair

iceage · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse, and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. X-rays may be needed if the patient has fallen recently and also has complaints of pain or decreased mobility. However, the nurse's first nursing action is to further assess the patient.

Answer to Question 2

ANS: A
Because the patient will be receiving antibiotics to treat the pneumonia, the nurse should be most concerned about her history of allergic rashes. The nurse needs to do further assessment of possible causes of the allergic rashes and whether she has ever had allergic reactions to any drugs, especially antibiotics. The assessment data in the other response would be normal for an older patient.