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
An audible thud without pain is a normal finding when percussing the costovertebral angle (CVA) in a healthy individual. This indicates that there is no inflammation or infection in the kidneys or surrounding tissues.
Choice B rationale
Sharp, severe pain upon percussion of the CVA is a classic sign of pyelonephritis. This pain is due to the inflammation and infection of the kidney, which causes tenderness in the area.
Choice C rationale
Rebound tenderness is typically associated with peritoneal irritation, such as in cases of appendicitis or peritonitis. It is not a common finding in pyelonephritis.
Choice D rationale
Rigidity and firmness are more indicative of muscle spasms or guarding, which can occur in conditions like peritonitis or severe abdominal pain, but not specifically in pyelonephritis.
Correct Answer is D
Explanation
Choice A rationale
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does.
Choice B rationale
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding.
Choice C rationale
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool.
Choice D rationale
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract.