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 C

Explanation

A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.

B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.

C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.

D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

A. Compare measured circumferences of each extremity joint. B. Instruct the client to walk across the room and observe the gait. C. Perform passive range of motion and compare the findings. D. Measure the length of each leg and document the findings.

Correct Answer is D

No explanation

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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

During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Correct Answer is D

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

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