When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?
Works in a day care center.
Adheres to a gluten-free diet.
Takes an oral anticoagulant.
Recently had dental surgery.
The Correct Answer is C
Choice A rationale
Working in a day care center may expose the client to minor injuries or infections, but it is not directly associated with widespread ecchymosis. Ecchymosis is more likely related to systemic issues rather than occupational hazards.
Choice B rationale
Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. Ecchymosis is not a typical manifestation of gluten intolerance.
Choice C rationale
Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood’s ability to clot, leading to bleeding into the skin and subsequent ecchymosis.
Choice D rationale
Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities.
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Correct Answer is B
Explanation
Choice A rationale
Asking if the client has been sleeping well is important for assessing overall health and identifying potential sleep disorders, but it may not directly address the immediate concerns related to the client’s expressionless facial affect, slurred speech, and red conjunctivae.
Choice B rationale
Asking if the client has ever had problems with blood sugar is crucial, as these symptoms could be indicative of hypoglycemia or hyperglycemia. Blood sugar imbalances can cause neurological symptoms such as slurred speech and changes in facial expression.
Choice C rationale
Asking if the client has had anything to eat in the last 24 hours is relevant for assessing nutritional status and potential hypoglycemia, but it may not provide immediate insight into the underlying cause of the symptoms.
Choice D rationale
Asking if the client has been depressed lately is important for assessing mental health, but it may not directly address the immediate physical symptoms the client is experiencing.
Correct Answer is C
Explanation
Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.