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?

Works in a day care center.

Adheres to a gluten-free diet.

Takes an oral anticoagulant.

Recently had dental surgery.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Working in a day care center may expose the client to minor injuries or infections, but it is not directly associated with widespread ecchymosis. Ecchymosis is more likely related to systemic issues rather than occupational hazards.
Choice B rationale
Adhering to a gluten-free diet is typically related to managing celiac disease or gluten intolerance, which primarily affects the gastrointestinal tract. Ecchymosis is not a typical manifestation of gluten intolerance.
Choice C rationale
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.
Choice D rationale
Dental surgery may involve procedures that could cause minor trauma to the oral tissues, leading to localized bruising around the mouth or jaw area. However, this localized bruising would typically not explain the presence of ecchymosis observed on the trunk and extremities.

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Correct Answer is C

Explanation

Choice A rationale
Offering to administer a laxative prescribed for PRN use is not appropriate in this situation, as the presence of rebound tenderness suggests a more serious underlying condition, such as appendicitis.
Choice B rationale
Obtaining a prescription to catheterize the client’s bladder is not indicated, as the symptoms are related to abdominal pain and rebound tenderness, not urinary retention.
Choice C rationale
Notifying the healthcare provider of the rebound tenderness is the appropriate action, as this finding could indicate a serious condition such as appendicitis. Prompt medical evaluation and intervention are necessary.
Choice D rationale
Instructing the client in distraction and relaxation techniques may help manage pain, but it does not address the underlying cause of the rebound tenderness. Immediate medical evaluation is required.

A. Elbow B. Wrist C. Shoulder

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"}}

No 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"}}

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