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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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Observing balance while the client stands assesses overall balance but does not specifically evaluate hip dysfunction.
Choice B rationale
Inspecting gluteal folds for symmetry can provide information about hip alignment but does not directly assess hip function.
Choice C rationale
Flexing the hip and knee while standing assesses range of motion but may not fully evaluate hip dysfunction.
Choice D rationale
Abducting each hip while the client is supine is a specific test to assess hip function and can help identify hip dysfunction.
Correct Answer is B
Explanation
ChoiceArationale
Abenignvariationwouldnottypicallypresentwithapatternofdullnessextendingfromthe 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern suggests an abnormality rather than a benign variation.
ChoiceBrationale
Cardiacenlargementisindicatedbyanareaofdullnessextendingfromthe5thleftintercostal space to the 2nd left intercostal space at the sternal border. This finding suggests an enlarged heart, which can be due to conditions such as cardiomegaly or left ventricular hypertrophy.
ChoiceCrationale
Cardiacatrophyrefersto adecreaseinthesizeormassoftheheartmuscle,resultingina smaller than normal heart. The described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
ChoiceDrationale
Anexpectedfindingwouldnottypicallypresentwiththedescribedpatternofdullness.The normal area of cardiac dullness is more limited and does not extend as described.