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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Using two middle fingers lightly applied to the thumb side of the wrist is correct. This technique ensures accurate detection of the radial pulse without excessive pressure, which could occlude the artery.
B. Firm pressure on the wrist along the fifth digit (ulnar side) is incorrect because the radial pulse is located on the thumb side of the wrist, not the ulnar side.
C. Using the bell of the stethoscope in the antecubital area is incorrect because this technique is used for blood pressure assessment, not radial pulse assessment.
D. Using the thumb and index finger to obliterate the pulse is incorrect because the thumb has its own pulse, which may lead to inaccurate readings.

A. Solid, dark brown color B. Asymmetric, irregular borders C. Flat with silvery scales D. Diameter of 3 mm

Correct Answer is B

Explanation

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

Correct Answer is A

Explanation

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

Correct Answer is B

Explanation

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?

What is the primary purpose of a nursing health assessment?

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?