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?

Takes an oral anticoagulant.

Works in a day care center.

Adheres to a gluten free diet.

Recently had dental surgery.

Answer and Explanation

The Correct Answer is A

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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Correct Answer is B

Explanation

A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.

B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.

C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.

D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Do you remember ever having this type of pain in the past?" D. "Does changing your position make the pain worse?

Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

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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

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