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 C
Explanation
Choice A rationale
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Tenderness upon palpation of the thoracic region is an abnormal finding and may indicate inflammation, infection, or other pathological conditions.
Choice B rationale
A thrill is a palpable vibration over the chest wall, often associated with turbulent blood flow due to cardiac abnormalities. It is not a normal finding in the thoracic region.
Choice C rationale
Non-tenderness upon palpation of the thoracic region is a normal finding, indicating the absence of inflammation, infection, or other abnormalities.
Choice D rationale
Crepitus is a crackling or popping sensation felt under the skin, often due to the presence of air in the subcutaneous tissue. It is not a normal finding and may indicate conditions such as pneumothorax or subcutaneous emphysema.
Correct Answer is C
Explanation
Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.