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?
Recently had dental surgery.
Takes an oral anticoagulant.
Adheres to a gluten free diet.
Works in a day care center.
The Correct Answer is B
Choice A Reason:
Recently had dental surgery is incorrect. Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising (ecchymosis) around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities. Therefore, while dental surgery may be relevant to the client's overall health history, it is less likely to directly relate to the widespread ecchymosis observed.
Choice B Reason:
Takes an oral anticoagulant is correct. 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. Therefore, this information is particularly important to follow up on as it may directly contribute to the observed ecchymosis.
Choice C Reason:
Adheres to a gluten-free diet is incorrect. Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. While celiac disease can be associated with certain skin conditions, ecchymosis is not a typical manifestation of gluten intolerance. Therefore, while this information may be relevant to the client's overall health, it is less likely to directly explain the observed ecchymosis.
Choice D Reason:
Works in a day care center is incorrect. Working in a day care center may involve activities that could result in minor injuries or bruises, but it is less likely to explain widespread ecchymosis observed on the trunk and extremities. While accidental injuries are possible in a daycare setting, they would typically be localized and not widespread. Therefore, while this information may be relevant to the client's occupation and risk of injury, it is less likely to directly relate to the observed ecchymosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.
Choice B Reason:
Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.
Choice C Reason:
Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.
Choice D Reason:
Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.
Correct Answer is C
Explanation
Choice A Reason:
Covering the inflamed area and notify the healthcare provider suggests taking precautions to protect the inflamed area and promptly informing the healthcare provider. While it's important to notify the healthcare provider about any concerning findings, covering the area without further assessment may prevent the nurse from gathering additional information that could be helpful in determining the cause of the lymph node enlargement.
Choice B Reason:
Auscultating the lymph node for the presence of a bruit involves listening for abnormal sounds (bruits) over the lymph node, which could indicate underlying vascular abnormalities. While it's important to assess lymph nodes for abnormalities, such as tenderness or enlargement, auscultation for bruits is not a standard assessment technique for lymph nodes.
Choice C Reason:
Asking the client about any localized tenderness at the site involves directly gathering information from the client about their experience of tenderness at the site of the enlarged lymph node. This information can provide valuable clues about the nature of the lymph node enlargement, such as whether it is inflamed due to infection or inflammation.
Choice D Reason:
Recording this normal finding in the assessment record assumes that the nurse considers the enlarged and visible lymph node as a normal finding. However, enlarged and visible lymph nodes are not typically considered normal and may indicate an underlying health issue that requires further assessment and intervention.
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