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 C rationale
Nontender firm lymph nodes are a significant finding that may indicate a more serious underlying condition, such as malignancy. This information is crucial for the healthcare provider to determine the next steps in diagnosis and treatment.
Choice A rationale
Recent over-the-counter infection cures are less relevant compared to the physical characteristics of the lymph nodes when assessing for potential malignancy.
Choice B rationale
The number of indoor cats at home is not directly related to the assessment of enlarged lymph nodes in the axilla.
Choice D rationale
The amount of daily caffeine consumption is not relevant to the assessment of enlarged lymph nodes in the axilla.

A. Paresthesia. B. Marginal decline in sensory function. C. Rebound reaction to the needle points. D. Normal sensory finding.

Correct Answer is D

Explanation

Choice A rationale
Paresthesia refers to abnormal sensations such as tingling or numbness, which is not indicated by the client’s ability to sense two points at specific distances.
Choice B rationale
A marginal decline in sensory function would be indicated by a significant increase in the distance required to sense two points, which is not the case here.
Choice C rationale
A rebound reaction to the needle points is not a recognized interpretation of the two-point discrimination test.
Choice D rationale
The client’s ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination.

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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 is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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