A nurse is completing a client abdominal assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
Round and Taut
White Striae
Symmetrical, Rounded shape
Soft and Non-Tender
The Correct Answer is B
A. Round and Taut:
A round and taut abdomen may be normal, depending on the individual's body habitus and muscle tone. It might indicate normal abdominal distension associated with gas or a meal.
B. White Striae (Stretch Marks)
White striae, commonly known as stretch marks, on the abdomen may warrant further investigation. While they are often benign and associated with conditions like weight gain or pregnancy, they can sometimes be indicative of underlying issues such as Cushing's syndrome or other factors. Further inquiry or investigation into the client's medical history may be needed to understand the cause of the white striae.
C. Symmetrical, Rounded Shape:
A symmetrical and rounded abdominal shape is generally considered a normal finding. It suggests that the abdominal muscles are intact and that there is no obvious asymmetry or abnormal protrusion.
D. Soft and Non-Tender:
A soft and non-tender abdomen is a normal finding. It suggests that the abdominal
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client if she is having pain.
This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.
B. Request a prescription for an antianxiety medication.
This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.
C. Request a prescription for an antihypertensive medication.
Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.
D. Return in 30 minutes to recheck the client’s blood pressure.
While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.
Correct Answer is ["A","D","E"]
Explanation
A. Client reports feeling dizzy when sitting up from a supine position.
Dizziness or lightheadedness when moving from a lying down to a sitting or standing position can be indicative of orthostatic hypotension.
B. Client reports feeling palpitations when rising from a supine to a standing position.
Palpitations (feeling of rapid or irregular heartbeat) can be associated with orthostatic changes and may indicate the heart's compensatory response to low blood pressure.
C. Erythema is present on the bilateral lower extremities.
Erythema (redness of the skin) is not typically associated with orthostatic hypotension. This symptom is more likely related to skin conditions or other causes.
D. The client has a temperature of 100.4 F.
Fever (elevated body temperature) is not a direct symptom of orthostatic hypotension. Orthostatic hypotension is primarily related to changes in blood pressure upon assuming an upright position.
E. The client states, “I feel lightheaded when sitting up.”
Lightheadedness upon sitting up or standing is a common symptom of orthostatic hypotension.
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