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 A
Explanation
Choice A rationale
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment.
Choice B rationale
Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.
Choice C rationale
Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.
Choice D rationale
Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.
Correct Answer is D
Explanation
Choice A rationale
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation.
Choice B rationale
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions, but the presence of a depressed umbilicus does not necessarily indicate scarring or previous surgery.
Choice C rationale
Asking about recent abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, but it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen.
Choice D rationale
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.