A 67-year-old male client is admitted to a health care facility with abdominal pain and suspected abdominal aneurysm. The client relates a 10-year history of high blood pressure and history of arterial insufficiency diagnosed 7 years ago. Following auscultation of the abdomen for bowel sounds, what other assessment should the nurse perform at this time?
Observe for evidence of increased abdominal girth.
Palpate the abdomen for masses, pulsations.
Auscultate for a friction rub.
Listen with the bell of the stethoscope for vascular sounds.
The Correct Answer is D
A. Observing for increased abdominal girth is important for conditions such as ascites but is not the priority assessment for a suspected abdominal aneurysm.
B. Palpating the abdomen for masses or pulsations is contraindicated in suspected abdominal aneurysms, as it may cause rupture.
C. Auscultating for a friction rub is used for liver or spleen inflammation and is not relevant in this case.
D. Listening with the bell of the stethoscope for vascular sounds is correct because an abdominal aneurysm may produce a bruit, which can be heard over the affected artery. This assessment helps confirm the presence of turbulent blood flow, a key sign of an aneurysm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.
Correct Answer is B
Explanation
A. Pneumonia typically presents with fever, productive cough, and crackles rather than wheezing and tripod positioning.
B. Chronic emphysema is correct. The tripod position (leaning forward, hands on knees) is a classic sign of severe obstructive lung disease, such as emphysema or COPD. Wheezing and dyspnea at rest suggest air trapping and difficulty exhaling, which are hallmarks of this condition. The oxygen saturation of 91% is common in COPD patients due to chronic hypoxemia.
C. Pneumothorax presents with sudden onset chest pain, absent breath sounds on one side, and tracheal deviation (if severe) rather than wheezing.
D. Congestive heart failure can cause dyspnea but typically presents with crackles due to pulmonary edema rather than wheezing and tripod positioning.
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