Ecchymosis refers to the discoloration of the skin resulting from bleeding underneath, typically due to bruising. While ecchymosis can occur for various reasons, the use of oral anticoagulants increases the risk of bleeding and bruising. Therefore, the nurse should further assess the client's use of oral anticoagulants to determine if it is contributing to the observed ecchymosis.

B. Works in a day care center:
Working in a day care center may expose the client to various infectious agents, but it is not directly associated with the development of ecchymosis.

C. Recently had dental surgery:
While dental surgery can sometimes result in minor bleeding and bruising, it is less likely to cause widespread ecchymosis unless there are underlying bleeding disorders or complications.

D. Adheres to a gluten-free diet:
Adhering to a gluten-free diet is not directly related to the development of ecchymosis. However, if the client has celiac disease or another condition requiring a gluten-free diet, the nurse should explore the potential for malabsorption or nutritional deficiencies, which could indirectly contribute to bleeding tendencies.

The symptoms described, including gnawing epigastric pain that worsens when hungry and improves after eating, are classic manifestations of peptic ulcer disease (PUD). Peptic ulcers are erosions in the mucosal lining of the stomach or duodenum, often caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs). The pain typically occurs when the stomach is empty and is relieved by food intake due to the buffering effect of food on gastric acid. This pattern of pain is known as "hunger pain" or "meal-related pain" and is characteristic of PUD.

A. Esophagitis:
Esophagitis refers to inflammation of the esophagus, often due to reflux of gastric contents into the esophagus. Symptoms may include heartburn, difficulty swallowing, and chest pain, but the pain is typically not related to hunger and food intake as described in the scenario.

C. Gastroesophageal reflux (GERD):
GERD involves the reflux of gastric contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. While GERD can cause epigastric discomfort, the described pattern of pain worsening with hunger and improving after eating is more indicative of PUD.

D. Chronic pancreatitis:
Chronic pancreatitis is characterized by inflammation and irreversible damage to the pancreas, leading to persistent abdominal pain, often radiating to the back. While epigastric pain is a feature of chronic pancreatitis, the relief of pain after eating is not typically seen, making it less likely in this scenario.

When unable to palpate peripheral pulses, particularly the pedal pulses, using a Doppler ultrasonic stethoscope is an appropriate action to further assess circulation. The Doppler device uses sound waves to detect and amplify blood flow, allowing the nurse to locate pulses that may be difficult to palpate by traditional means. This assessment technique can provide valuable information about vascular status and potential circulation issues in the extremities.

B. Notify the healthcare provider:
Notifying the healthcare provider is not the initial action for the inability to palpate pedal pulses. The nurse should first attempt to assess the pulses using alternative methods, such as a Doppler device, before escalating the concern to the provider.

C. Apply warm blankets to both feet:
Applying warm blankets may be appropriate for clients with cold extremities due to peripheral vasoconstriction, but it does not directly address the issue of being unable to palpate pulses. Additionally, warmth alone may not improve circulation if there is an underlying vascular problem causing the absence of pulses.

D. Palpate pulse points with legs dependent:
Palpating pulse points with the legs dependent may facilitate blood flow to the lower extremities, potentially making pulses easier to palpate. However, if pulses are not palpable in the supine or seated position, it is unlikely that changing positions will significantly improve their detectability. Using a Doppler device would be a more appropriate next step in this situation.

A. Number of blood clots expelled with each stool:
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does. Therefore, although it may be noted, it is not the most crucial aspect to document initially.

B. Evidence of internal hemorrhoids:
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding, so a comprehensive assessment of the stool is necessary.

C. Unique odor noted with gastrointestinal bleeding:
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool, which can help identify potential causes of bleeding.

D. Color characteristics of each stool:
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract. Describing the color, consistency, and presence of any abnormal substances in the stool helps healthcare providers assess the severity and potential causes of the bleeding.

A. Encourage fluid intake:
Encouraging fluid intake is the most appropriate action for the client experiencing gout, as it helps to promote the excretion of uric acid through urine. Increased fluid intake can help prevent the formation of urate crystals in the joints and reduce the severity and frequency of gout attacks. It is a fundamental aspect of managing gout and preventing future episodes.

B. Measure urine output:
While monitoring urine output is important for overall assessment, it is not specifically indicated in the management of acute gout attacks. Gout is primarily managed by addressing hyperuricemia and reducing inflammation in the affected joints, which is best achieved through hydration and pharmacological interventions.

C. Splint the affected joint:
Splinting the affected joint may provide some relief by immobilizing it and reducing movement, but it does not address the underlying cause of gout or promote the excretion of uric acid. Splinting is more commonly used in the management of injuries or conditions that require joint stabilization.

D. Increase intake of red meat:
Increasing intake of red meat is contraindicated in clients with gout because red meat contains high levels of purines, which can exacerbate hyperuricemia and increase the risk of gout attacks. Dietary modifications for gout typically involve reducing the consumption of foods high in purines, such as red meat, organ meats, and certain seafood.

Answer: D

Rationale:

A) Tenderness:

Tenderness upon palpation is not considered a normal finding. It may indicate inflammation, injury, or other underlying conditions affecting the thoracic region. Tenderness requires further investigation to determine the cause and appropriate treatment.

B) Crepitus:

Crepitus, which is a crackling or popping sensation felt under the skin, is not a normal finding. It can be associated with subcutaneous air or gas, often resulting from trauma or infection. Identifying crepitus prompts further evaluation to determine the underlying issue.

C) Thrill:

A thrill is a palpable vibration or sensation over the chest, typically felt over an area of turbulent blood flow, such as a heart murmur. It is not considered a normal finding in the thoracic region and usually indicates an abnormal cardiovascular condition that requires further assessment.

D) Non-tender:

A non-tender thoracic region is considered a normal finding. Absence of tenderness upon palpation indicates no immediate signs of inflammation or injury in the thoracic area, suggesting that the palpation findings are within the expected range of normal physical examination.

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

A. Deep, continuous pain in the calf muscles:
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth:
Painful symptoms alleviated by warmth are more characteristic of arterial insufficiency, such as in peripheral arterial disease (PAD), rather than venous insufficiency.

C. Cool, pale skin below the knees:
Cool, pale skin below the knees is also more suggestive of arterial insufficiency rather than venous insufficiency. Arterial insufficiency often presents with decreased blood flow to the extremities, resulting in coolness and pallor.

D. Decreased pain when legs are elevated:
This is the correct answer. Venous insufficiency typically results in symptoms such as aching, tired legs, and swelling, which worsen with prolonged standing but improve with leg elevation. This is due to the reduction in venous pressure when the legs are elevated, which helps alleviate symptoms associated with venous congestion and stasis.

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

A) Compare the shape of each of the pupils bilaterally with normal room light:
Assessing the shape of the pupils with normal room light is not specifically related to assessing pupillary reaction to accommodation. This action may be more relevant for assessing pupillary symmetry and shape, but it does not directly evaluate accommodation.

B) Determine if dilation of the pupils occurs when the room is darkened:
This action assesses the pupillary response to changes in light (pupillary light reflex), not specifically accommodation. While it is an important assessment, it does not target accommodation specifically.

C) Note the speed of pupil constriction when a penlight is shined into the eye:
This action assesses the pupillary light reflex, which involves the constriction of the pupils in response to light. While it is related to pupillary function, it does not specifically evaluate accommodation.

D) Observe pupil size when focusing on a near object and then a far object:
This action directly assesses the pupillary reaction to accommodation. When focusing on a near object, the pupils should constrict (miosis), and when focusing on a far object, the pupils should dilate (mydriasis). This response indicates that the pupils are adapting to changes in focal distance, demonstrating accommodation.