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 A

Explanation

Choice A rationale
Generalized lumpiness of both breasts with no discrete masses and no nipple discharge is a common finding, especially before menstrual periods. Assuring the client that her breasts are normal and advising annual evaluations is appropriate.
Choice B rationale
Requesting a return visit after her menstrual period for a breast exam re-check is unnecessary if the findings are consistent with normal premenstrual changes.
Choice C rationale
Explaining to the client that an ultrasound of the breast will likely be necessary is not warranted based on the current findings.
Choice D rationale
Suggesting that the client schedule a mammogram after her next menstrual period is not necessary for a young adolescent with normal premenstrual breast changes.

A. Continue with the remainder of the client’s physical assessment. B. Report the client’s abnormal lung sounds to the healthcare provider. C. Ask the client to cough and then auscultate at the site again. D. Measure the client’s oxygen saturation with a pulse oximeter.

Correct Answer is A

Explanation

Choice A rationale
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment.
Choice B rationale
Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.
Choice C rationale
Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.
Choice D rationale
Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.

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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

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Correct Answer is A

Explanation

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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?

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

During an admission assessment, which approach should the nurse use to assess a client’s speech patterns?

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?