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: Administering oxygen via nasal cannula is the first priority in this scenario. The client’s oxygen saturation is 88% on room air, which indicates hypoxemia. Providing supplemental oxygen will help improve the client’s oxygenation and alleviate symptoms of shortness of breath. Ensuring adequate oxygenation is crucial to prevent further respiratory distress and potential complications.
Choice B rationale: Obtaining a sputum culture is important to identify the causative organism of the client’s respiratory infection and guide appropriate antibiotic therapy. However, this action is not the immediate priority. Addressing the client’s hypoxemia by administering oxygen takes precedence to stabilize the client’s condition.
Choice C rationale: Administering an antipyretic medication can help reduce the client’s fever and improve comfort. However, this is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen.
Choice D rationale: Encouraging the client to increase fluid intake is important for maintaining hydration and helping to thin respiratory secretions. However, this action is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen
Correct Answer is B
Explanation
Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect