The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Hematoma.

Vesicle.

Ecchymosis.

Petechiae.

Answer and Explanation

The Correct Answer is D

A.   A hematoma refers to a collection of blood outside of blood vessels, typically resulting in a bruise or swelling. The description of round, flat, pinpoint red spots does not suggest this type of injury.
B.   Vesicles are small fluid-filled blisters, which do not match the description of the pinpoint red spots. Vesicles would be more elevated and contain fluid.
C.   Ecchymosis refers to a bruise, or large, irregular areas of discoloration caused by blood leaking into the tissues. The description of pinpoint red spots suggests petechiae, not ecchymosis.
D.   Petechiae are small, round, flat, pinpoint red or purple spots that occur when small blood vessels (capillaries) break under the skin. This is the most appropriate description for the observed finding, particularly in the context of trauma from intimate partner violence.

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Correct Answer is D

Explanation

A. While comparing the range of motion of both legs could be useful for detecting joint or muscle- related issues, it does not directly address the vascular concerns suggested by the shiny skin and absence of hair growth. These signs are more likely related to poor circulation, which requires different diagnostic approaches.
B. Asking about feelings of weakness or hunger may be more relevant to assessing the client’s blood glucose control, but it is not directly related to the symptoms of shiny skin and hair loss on the lower legs, which suggest peripheral vascular changes common in diabetes.
C. While measuring blood glucose levels is important in managing diabetes, it will not help to assess the vascular insufficiency suggested by the physical findings. However, managing blood glucose is crucial to preventing further complications.
D. Palpating the dorsalis pedis pulses is the most appropriate next step. Decreased or absent pulses in the feet and lower extremities are commonly associated with peripheral vascular disease, which is common in clients with diabetes due to poor circulation.

A. Blowing, hollow sounds above sternum. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Right breath sounds louder than left.

Correct Answer is D

Explanation

A. Blowing or hollow sounds above the sternum are abnormal and may suggest a condition like aortic or pulmonary disease. Such sounds are not typical during routine chest auscultation and may indicate pathology like bronchial obstruction or an abnormal vascular sound.
B. Slight crackling sounds, also known as "rales" or "crackles," may be indicative of fluid accumulation in the lungs, often seen in conditions like pneumonia or congestive heart failure. These are not considered normal findings and warrant further evaluation.
C. Faint whistling sounds may be indicative of wheezing, which is often a sign of airway narrowing or obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). Wheezing is not typically considered normal and should be investigated further.
D. Right-sided breath sounds being louder than the left could be a normal finding in certain individuals, depending on factors like body position or anatomical variations. In a healthy individual, this difference may not indicate pathology unless associated with other symptoms such as asymmetry in lung sounds or dyspnea.

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The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

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Naxlex Comprehensive Predictor Exams

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is D

Explanation

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Correct Answer is D

Explanation

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