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 C

Explanation

A. While it is important to palpate the correct quadrant, this is unlikely the cause if the gallbladder cannot be located. The gallbladder is typically located in the right upper quadrant, and the nurse would have been palpating this area. This option does not address the most likely cause.
B. A normal gallbladder might not always be palpable, especially if the client is obese. However, inability to palpate the gallbladder does not necessarily indicate a problem; this is a common finding in obese individuals where fat tissue can obscure the gallbladder.
C. Obesity can make it more difficult to palpate internal structures such as the gallbladder. Excess adipose tissue in the abdominal area can prevent the nurse from feeling the gallbladder during palpation. This is the most likely explanation for the failure to locate the gallbladder.
D. While deeper palpation might be necessary in obese clients, the inability to palpate the gallbladder is more likely due to the obscuring effects of fat, rather than a technique issue. It's a common finding that obesity hinders the ability to palpate organs like the gallbladder.

A. Observe for any facial asymmetry. B. Determine the response to stimuli. C. Assess for a positive Romberg sign. D. Check the pupillary response to light.

Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

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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

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is C

Explanation

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

Correct Answer is B

Explanation

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