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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Condition: Pleural Effusion
Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment).
Actions to Take:
- Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted.
- Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment.
Parameters to Monitor:
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Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation.
- Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.
Correct Answer is C
Explanation
A. While this approach may seem less intrusive, it can create confusion and may prevent the client from feeling fully understood. Asking vague questions could make it more difficult to get useful information about the client's health concerns.
B. Sharing personal values is generally not appropriate in a clinical interview, as it could create boundaries that compromise the professional relationship. The nurse should maintain objectivity and empathy without sharing personal beliefs.
C. Starting with less sensitive questions allows the nurse to build rapport and trust with the client before delving into more personal or difficult topics. This approach is helpful in easing the client into more sensitive discussions.
D. Asking the most difficult questions right away can overwhelm the client, especially if they are hesitant or uncomfortable. It is better to establish a trusting relationship first and allow the client to open up at their own pace.
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