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 B

Explanation

A. While anxiety and fear can accompany many medical conditions, they are not typically associated with appendicitis. Appendicitis is characterized by physical symptoms like pain and digestive disturbances rather than emotional symptoms.
B. Periumbilical pain that shifts to the right lower quadrant is the classic presentation of appendicitis. As the inflammation progresses, pain tends to move from the mid-abdomen to the lower right abdomen, which supports a diagnosis of appendicitis.
C. Diffuse abdominal pain is less specific and could indicate a variety of conditions. While an elevated neutrophil count can suggest infection or inflammation, the localized pain seen in appendicitis is a more distinguishing feature.
D. These symptoms are also common in appendicitis, as it typically presents with loss of appetite, nausea, and fever. However, the hallmark symptom is localized pain, particularly in the right lower quadrant, making B a stronger indication.

A. History of a fractured patella. B. Needle aspiration of the synovial space. C. Knee arthroplasty surgery. D. Degenerative disease.

Correct Answer is D

Explanation

A. A history of a fractured patella could potentially cause crepitation if there were long-term damage or improper healing. However, it is more likely that crepitation is related to degenerative changes, such as osteoarthritis.
B. Needle aspiration of the synovial space may have been performed to relieve fluid buildup or inflammation, but it would not directly explain the crepitation in the joint. Crepitation is more commonly seen in conditions that affect cartilage or joint surfaces.
C. Crepitation following knee arthroplasty is possible if there are complications, but it is more likely due to arthritis or degenerative joint disease if the patient has not undergone surgery. Arthroplasty would usually be associated with reduced crepitation.
D. Degenerative diseases, such as osteoarthritis, are the most likely cause of crepitation. As the cartilage wears away, the bone surfaces rub together, causing the characteristic crunching or grating sound when the joint is moved.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is B

Explanation

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

Correct Answer is D

Explanation

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