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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain a dietary consultation for nutrition teaching: Diet might play a role in some thyroid conditions, but a referral for dietary consultation wouldn't be the first step.
B. Instruct the client in the need to use iodized salt: Iodine deficiency can cause goiter (enlarged thyroid gland), but most table salt in developed countries is iodized.
C. Request diagnostic laboratory testing for the client: This is the most appropriate next step. Blood tests can help determine the cause of the enlarged thyroid gland.
D. Schedule a follow-up appointment in one month: A follow-up might be needed, but further workup is essential to determine the cause of the finding.
Correct Answer is B
Explanation
A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.
B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.
C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.
D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.
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