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 C

Explanation

Choice A Reason:
Listening while the client reads items listed on the menu is inappropriate. This approach involves assessing the client's speech while they read items listed on the menu. While reading aloud can provide some insight into speech patterns, it may not fully capture spontaneous speech or natural conversation. Additionally, reading may not necessarily assess other aspects of speech such as articulation, fluency, or coherence. Therefore, while this approach can offer some information, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice B Reason:
Asking the client to complete a common proverb or saying is inappropriate. Asking the client to complete a common proverb or saying is a task that assesses language comprehension and expression. While this approach may provide some insight into the client's ability to formulate and articulate speech, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, completing proverbs or sayings may require specific cultural knowledge or cognitive abilities that could influence the assessment. Therefore, while this approach can be useful in certain contexts, it may not be as comprehensive as observing speech during a natural conversation or interview.
Choice C Reason:
Noting the client's responses during the initial interview is appropriate. Option C involves observing the client's speech patterns during the initial interview, which provides the nurse with an opportunity to assess spontaneous speech, articulation, fluency, and coherence. During the initial interview, the nurse can assess the client's ability to express thoughts, respond to questions, and engage in conversation, which can reveal any abnormalities or difficulties in speech patterns. This approach allows for a comprehensive assessment of speech without requiring specific tasks or prompts that may be more challenging or unfamiliar to the client.
Choice D Reason:
Having the client repeat a phrase containing alliteration is inappropriate. Asking the client to repeat a phrase containing alliteration is a task that assesses speech articulation and phonological skills. While this approach may provide some information about the client's ability to produce specific sounds or syllables, it may not fully capture spontaneous speech patterns or natural conversation. Additionally, repeating phrases with alliteration may not necessarily assess other aspects of speech such as fluency, coherence, or language comprehension. Therefore, while this approach can be useful for assessing specific speech skills, it may not be as comprehensive as observing speech during a natural conversation or interview.

A. Review the client's serum electrolytes. B. Evaluate client's muscle strength and hand grips. C. Check distal phalanges capillary refill. D. Observe skin for erythema, edema, and warmth.

Correct Answer is B

Explanation

Choice A Reason:
Reviewing the client's serum electrolytes is incorrect. While abnormalities in electrolyte levels can sometimes contribute to neurological symptoms, such as paresthesia, reviewing the client's serum electrolytes may not directly identify additional findings consistent with the client's reported paresthesia of the hands and legs. Therefore, this option is less relevant for assessing paresthesia and identifying additional consistent findings.
Choice B Reason:
This is the correct action to identify additional findings consistent with the client's paresthesia. Paresthesia, or abnormal sensations like burning or tingling, may indicate neurological dysfunction. Assessing the client's muscle strength and hand grips can provide valuable information about neurological function and help identify any weakness or changes that may be associated with the paresthesia.
Choice C Reason:
Checking distal phalanges capillary refill is incorrect. Checking distal phalanges capillary refill is important for assessing peripheral circulation, but it may not directly identify additional findings consistent with paresthesia. While impaired circulation could contribute to sensory disturbances, such as paresthesia, it is not always the primary cause. Therefore, this option may not fully capture the sensory aspect of the client's reported symptoms.
Choice D Reason:
While observing the skin for signs of inflammation or irritation is important in assessing for other conditions, such as infection or inflammation, it is not directly related to identifying additional findings consistent with paresthesia. Paresthesia primarily involves abnormal sensations and neurological function rather than changes in the skin.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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?