When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Recently had dental surgery.

Takes an oral anticoagulant.

Adheres to a gluten free diet.

Works in a day care center.

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Recently had dental surgery is incorrect. Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising (ecchymosis) around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities. Therefore, while dental surgery may be relevant to the client's overall health history, it is less likely to directly relate to the widespread ecchymosis observed.
Choice B Reason:
Takes an oral anticoagulant is correct. Taking an oral anticoagulant medication increases the risk of bleeding, which can manifest as ecchymosis (bruising) on the skin. Anticoagulants such as warfarin or aspirin can interfere with the blood's ability to clot, leading to bleeding into the skin and subsequent ecchymosis. Therefore, this information is particularly important to follow up on as it may directly contribute to the observed ecchymosis.
Choice C Reason:
Adheres to a gluten-free diet is incorrect. Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. While celiac disease can be associated with certain skin conditions, ecchymosis is not a typical manifestation of gluten intolerance. Therefore, while this information may be relevant to the client's overall health, it is less likely to directly explain the observed ecchymosis.
Choice D Reason:
Works in a day care center is incorrect. Working in a day care center may involve activities that could result in minor injuries or bruises, but it is less likely to explain widespread ecchymosis observed on the trunk and extremities. While accidental injuries are possible in a daycare setting, they would typically be localized and not widespread. Therefore, while this information may be relevant to the client's occupation and risk of injury, it is less likely to directly relate to the observed ecchymosis.

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Correct Answer is D

Explanation

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

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

Correct Answer is C

Explanation

Choice A Reason:
History of a fractured patella is incorrect. While a history of a fractured patella may lead to some degree of crepitation in the knee joint, especially if there was damage to the articular surfaces during the injury, it is less likely to cause widespread crepitation with joint movement. Crepitation associated with a fractured patella would typically be localized to the site of injury rather than throughout the joint.
Choice B Reason:
Knee arthroplasty surgery is incorrect. Knee arthroplasty surgery involves the replacement of a damaged knee joint with an artificial prosthesis. While crepitation can occur in some cases following knee arthroplasty, it is less likely to be the cause of crepitation observed in this scenario, especially if the client's knee arthroplasty was successful and without complications.
Choice C Reason:
Degenerative disease is correct. Degenerative disease of the knee joint, such as osteoarthritis, is a common cause of crepitation during joint movement. Osteoarthritis is characterized by the breakdown of cartilage in the joints, leading to friction between bones and resulting in crepitus. This condition is often associated with aging, repetitive stress on the joints, or underlying joint abnormalities.

Choice D Reason:
Needle aspiration of the synovial space is incorrect. Needle aspiration of the synovial space is a procedure performed to remove excess fluid or to obtain a sample of synovial fluid for diagnostic purposes. While this procedure may be performed for various reasons, it is not directly associated with crepitation in the knee joint.

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When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is D

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 C

Explanation

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