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. Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B. Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C. Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D. Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

A. Hernia. B. Aneurysm. C. Tympany. D. Appendicitis.

Correct Answer is B

Explanation

A. A hernia may present as a bulge in the abdomen, but it is not typically pulsating. It is usually a soft, non-pulsatile mass.
B. A pulsating centrally localized abdominal distention is characteristic of an abdominal aneurysm, which occurs when the wall of the aorta weakens and bulges. The pulsation is often palpable and can be dangerous if ruptured.
C. Tympany refers to a sound produced during percussion, which is typically heard over air-filled structures like the stomach, but it doesn’t cause pulsating distention.
D. Appendicitis typically presents with localized pain in the lower right abdomen and is not associated with pulsating abdominal distention.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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