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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?

A.

Works in a day care center.

B.

Adheres to a gluten-free diet.

C.

Takes an oral anticoagulant.

D.

Recently had dental surgery.

Answer and Explanation

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 C

Explanation

Choice A rationale

Asking the client if he knows the year he married his wife assesses long-term memory, not recent memory.

Choice B rationale

Determining if the client can recall what he ate for breakfast assesses recent memory but does not provide a comprehensive assessment.

Choice C rationale

Instructing the client to follow a three-step task assesses the client’s ability to process and remember recent information, providing a more thorough evaluation of recent memory.

Choice D rationale

Telling the client to repeat a series of unrelated numbers assesses short-term memory and attention, not specifically recent memory.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Packs of cigarettes smoked per day is essential information for calculating smoking pack years.

Choice B rationale

The number of attempts to quit smoking is not required for calculating smoking pack years.

Choice C rationale

The client’s current age is not required for calculating smoking pack years.

Choice D rationale

The age when the client started smoking is necessary to determine the total number of years smoked.

Choice E rationale

The number of years the client smoked is essential for calculating smoking pack years.

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