A client in the emergency room is being admitted with severe right lower quadrant abdominal pain. The client states the pain is an 8 on the scale of 0-10 with sharp intermittent pain that has not been relieved by any intervention at this point. What will the nurse ask the client to do while palpating the abdomen?

Have the client lay on their left side.

Ask the client to exhale and hold their breath.

Encourage the client to raise their head off the pillow.

Assist the client in flexing their knees.

Answer and Explanation

The Correct Answer is D

A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.

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Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

A. Carbohydrate deficiency B. Vitamin B12 deficiency C. Protein deficiency D. Vitamin A deficiency

Correct Answer is C

Explanation

A. Carbohydrate deficiency can lead to low energy levels and weight loss, but it is not primarily associated with edema, brittle nails, or dry hair.
B. Vitamin B12 deficiency can cause neurological symptoms and anemia, but it does not typically lead to edema or brittle nails.
C. Protein deficiency is correct because it can cause muscle wasting, poor wound healing, thin and dry hair, brittle nails, and edema due to low albumin levels.
D. Vitamin A deficiency is primarily linked to vision problems, dry skin, and an increased risk of infections but does not typically cause edema or brittle nails.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

Correct Answer is C

Explanation

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?

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?