A client comes to the emergency department with severe pain and tenderness in the groin area. The nurse suspects an incarcerated hernia. Which of the following assessments should the nurse prioritize?
Assessing the client's blood pressure and heart rate.
Obtaining a detailed history of the client's diet and eating habits.
Evaluating the client's range of motion and joint flexibility.
Monitoring the client's oxygen saturation and respiratory rate.
The Correct Answer is A
Choice A reason:
This statement is correct. Assessing the client's blood pressure and heart rate is a priority in a client with an incarcerated hernia as it can indicate signs of compromised blood flow to the herniated tissue and potential strangulation.
Choice B reason:
Obtaining a detailed history of the client's diet and eating habits may be important for certain conditions, but it is not a priority assessment in a client with a suspected incarcerated hernia.
Choice C reason:
Evaluating the client's range of motion and joint flexibility may be relevant for musculoskeletal assessments, but it is not a priority in a client with a suspected incarcerated hernia.
Choice D reason:
Monitoring the client's oxygen saturation and respiratory rate may be important in various conditions, but it is not a priority assessment in a client with a suspected incarcerated hernia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This statement is correct. Hernias occur when an organ, such as the intestine or abdominal tissue, protrudes through a weakened area in the muscle or connective tissue.
Choice B reason:
This statement is correct. Heavy lifting, straining during bowel movements, or activities that increase intra-abdominal pressure can contribute to the development of hernias.
Choice C reason:
This statement is incorrect and indicates a need for further teaching. Not all hernias are visible as bulging lumps under the skin. Some hernias may not be externally noticeable and are diagnosed through imaging studies.
Choice D reason:
This statement is correct. Surgery is often the primary treatment for most types of hernias to repair the weakened area and prevent complications.
Correct Answer is D
Explanation
Choice A reason:
Having the client lift their legs while lying on their back is not a maneuver used to assess for a hiatal hernia. This position is more commonly used to assess for inguinal or femoral hernias in the groin area.
Choice B reason:
Palpating the abdomen for tender areas or masses is a general abdominal assessment and may not specifically assess for a hiatal hernia.
Choice C reason:
Auscultating for bowel sounds in all quadrants of the abdomen is also part of a general abdominal assessment and does not specifically target a hiatal hernia.
Choice D reason:
This statement is correct. Asking the client to take a deep breath and palpating the upper abdomen can help the nurse assess for a hiatal hernia. The nurse may feel for a soft bulge or protrusion in the upper abdominal area, which may indicate a hiatal hernia.
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