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?

Takes an oral anticoagulant.

Works in a day care center.

Adheres to a gluten free diet.

Recently had dental surgery.

Answer and Explanation

The Correct Answer is A

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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Correct Answer is B

Explanation

A. Multiple maculopapular pustules over forehead and chin on an adolescent student: These pustules could be indicative of an infectious process, such as acne or impetigo. While not necessarily an emergency, it’s important to assess and potentially treat these skin lesions promptly. The school nurse should report this to the healthcare provider for further evaluation.

B. Red, swollen, painful nodule located on the upper back of a school-aged student: This finding raises concern for an abscess or localized infection. The pain, redness, and swelling suggest an inflammatory process. The nurse should promptly report this to the healthcare provider for assessment and appropriate management.

C. Small, white flecks on the hair shafts throughout the scalp on a school-aged child: These white flecks are likely nits (lice eggs). While not an emergency, they do require attention. The nurse should inform the parents or guardians and recommend appropriate treatment. However, this finding does not necessitate immediate reporting to the healthcare provider.

D. Bilateral patellar abrasions with eschar formation on a preschool-aged student: Abrasions with eschar (dead tissue) formation can indicate a deeper injury. The nurse should report this to the healthcare provider promptly for assessment and wound care recommendations.

A. Auscultate the lymph node for the presence of a bruit. B. Ask the client about any localized tenderness at the site. C. Cover the inflamed area and notify the healthcare provider. D. Record this normal finding in the assessment record.

Correct Answer is B

Explanation

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

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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 B

Explanation

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Correct Answer is B

Explanation

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