The home health nurse observes several small, round bruises on the back side of an elderly client's arms. What action by the nurse is indicated first?

Correct Answer: A

Rationale: The correct answer is A: Question the client about the cause of the bruises. This is the first action indicated because it allows the nurse to gather more information directly from the client to understand the potential cause of the bruises. By communicating with the client, the nurse can assess if the bruises are due to accidental bumps, medication side effects, abuse, or other underlying health issues. This direct communication is crucial for determining the appropriate follow-up actions. Summary of other choices: B: Discussing with the client's spouse does not directly involve the client, who should be the primary source of information. C: Documenting the bruises is important but does not address the immediate need to gather more information from the client. D: Contacting the supervisor is premature without first gathering information from the client.

Correct Answer: A

Rationale: Rationale: At 4 weeks pregnant, progesterone levels are expected to rise to support the pregnancy. A lower than expected progesterone level could indicate a potential issue with maintaining the pregnancy. Estrogen levels also rise during pregnancy, so B is incorrect. Prostaglandins are not typically measured in routine pregnancy assessments, making C irrelevant. Luteinizing hormone levels decrease after ovulation and remain low during pregnancy, so D is also incorrect.

Correct Answer: B

Rationale: The correct answer is B: Male condoms. Condoms provide a physical barrier that can significantly reduce the risk of sexually transmitted infections (STIs) by preventing direct contact between bodily fluids. They are the most effective method for STI protection. Oral contraceptives (A) do not protect against STIs. Sponges (C) and spermicides (D) offer some pregnancy protection but do not provide significant STI protection like condoms do.

Correct Answer: D

Rationale: The correct action is to assess the right leg for pulses, skin color, and temperature first. This is essential to determine the perfusion and circulation to the affected area. Assessing for pulses helps in evaluating blood flow, skin color indicates tissue perfusion, and temperature can indicate infection or compromised blood flow. This assessment is crucial in identifying any circulation issues that may exacerbate the pressure ulcer. Drawing blood for lab tests (Choice A) is important but not the priority. Obtaining a wound culture (Choice B) and elevating the foot (Choice C) are important interventions but should come after assessing circulation to address the underlying cause of the pressure ulcer.

Correct Answer: A

Rationale: The correct answer is A: Use a lift sheet when moving the client in bed. This intervention is crucial for preventing skin breakdown in older adults as it reduces friction and shear forces on the skin. Moving the client without a lift sheet can cause pressure ulcers. Avoiding tape (B) is important to prevent skin irritation but not specifically for skin breakdown prevention. Whirlpool therapy (C) can be beneficial for wound healing but is not directly related to preventing skin breakdown. Using loose dressings (D) may not provide adequate protection and could lead to further complications.