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: Ask when the adolescent was last seen in the clinic. This option might help confirm the identity and recent activity of the patient, but it does not address the primary issue of confidentiality and privacy regarding the adolescent's medical information. Simply asking when the adolescent was last seen does not change the legal requirement to obtain consent from the patient who is now an adult.

B: Explain that the information cannot be released without the 18-year-old's permission. This is the most appropriate response. Once an individual turn 18, they are legally an adult and their health information is protected under the Health Insurance Portability and Accountability Act (HIPAA) in the United States, or similar privacy laws in other countries. Without explicit permission from the 18-year-old patient, the nurse cannot legally release medical information to anyone else, including parents.

C: Tell the mother to have the teenager call the clinic. While this response encourages the teenager to take responsibility for their own healthcare, it does not address the immediate concern of the mother inquiring about the results. It shifts the responsibility to the adolescent but doesn't explain why the mother cannot be given the information. It's a partial solution but lacks clarity on the confidentiality issue.

D: Since the serum samples were drawn last week, provide the mother with the findings. This option is inappropriate and violates HIPAA regulations. Regardless of when the serum samples were drawn, the patient is now legally an adult and the information cannot be shared without their explicit consent. Providing the mother with the findings would be a breach of the adolescent's privacy and legal rights.

A. Description of head pain. B. Concentrated urine output. C. Bruising on both arms. D. Blood glucose is 160 mg/dL (8.88 mmol/L).

Correct Answer is D

Explanation

A Description of head pain: While head pain can be a concern after an MVC, it doesn't necessarily require immediate intervention based on the information provided.

B. Concentrated urine output: Concentrated urine can suggest dehydration, but it's not the most urgent finding in this scenario.

C. Bruising on both arms: Bruising is a common consequence of an MVC and doesn't require immediate intervention.

D. Blood glucose is 160 mg/dL (8.88 mmol/L): This blood sugar level is above the normal reference range and could indicate hyperglycaemia (high blood sugar). In an older adult, especially after a stressful event like an MVC, it's crucial to address this as it can worsen confusion and other symptoms.

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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's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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