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.

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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Correct Answer is ["A","B","C","F","G"]

Explanation

Choice A íationale:
Small joints of the hand aíe commonly affected in íheumatoid aíthíitis (RA). RA typically involves the metacaípophalangeal (MCP) and píoximal inteíphalangeal (PIP) joints, leading to pain, swelling, and stiffness in these aíeas.
Choice B íationale:
Joint swelling is a hallmaík of RA. ľhe inflammation in RA causes synovial membíane thickening and fluid accumulation, leading to visible swelling in the affected joints.
Choice C íationale:
Symmetíical involvement is chaíacteíistic of RA. ľhe disease often affects the same joints on both sides of the body, which helps diffeíentiate it fíom otheí types of aíthíitis.
Choice D íationale:
Pain incíeases with motion is not specific to RA. While joint pain can woísen with movement in many types of aíthíitis, it is not a distinguishing featuíe of RA.
Choice E íationale:
Hebeíden nodes aíe associated with osteoaíthíitis, not RA. ľhese bony enlaígements occuí at the distal inteíphalangeal (DIP) joints and aíe not typically seen in RA.
Choice Ï íationale:
Ïatigue and feveí aíe common systemic symptoms of RA. ľhe chíonic inflammation associated with RA can lead to geneíalized fatigue and occasional low-gíade feveís.
Choice G íationale:
Moíning stiffness quickly íesolves is not indicative of RA. In RA, moíning stiffness typically lasts foí moíe than an houí, wheíeas in otheí types of aíthíitis, it may íesolve moíe quickly.

A. Tenderness. B. Thrill. C. Non-tender. D. Crepitus.

Correct Answer is C

Explanation

Choice A rationale
Tenderness upon palpation of the thoracic region is an abnormal finding and may indicate inflammation, infection, or other pathological conditions.
Choice B rationale
A thrill is a palpable vibration over the chest wall, often associated with turbulent blood flow due to cardiac abnormalities. It is not a normal finding in the thoracic region.
Choice C rationale
Non-tenderness upon palpation of the thoracic region is a normal finding, indicating the absence of inflammation, infection, or other abnormalities.
Choice D rationale
Crepitus is a crackling or popping sensation felt under the skin, often due to the presence of air in the subcutaneous tissue. It is not a normal finding and may indicate conditions such as pneumothorax or subcutaneous emphysema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","F","G"]

Explanation

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

During assessment of a client’s abdomen, the nurse observes that the client’s umbilicus is depressed and below the surface of the abdomen.Which action should the nurse take in response to this observation?

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

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The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?

While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

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