Which client finding is most important for the nurse to follow up?

Question

Quizplus · Accepted Answer

Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia. (Option A) The normal finding is a soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin. An abnormal finding would be a boggy liver edge below the rib cage (hepatomegaly). (Option B) Kidney inflammation (pyelonephritis) results in positive costovertebral angle (CVA) tenderness tenderness in the back/flank. It is an expected finding that is elicited when the examiner places the hand over the client's lower back and places the other hand on top and makes a fist to gently "thump" or tap the area. (Option D) The Babinski sign can indicate an upper motor neuron lesion from damage to the corticospinal tract. A normal finding for an adult is for the toes to point downward. Educational objective: Purpura refers to purplish blotches indicating bleeding underneath the skin; it is a significant finding that requires further assessment.

Which Client Finding Is most Important for the Nurse to Follow