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 ["C","E"]
Explanation
A. Place the client in semi-Fowler’s position:
While the semi-Fowler's position can be helpful in assessing respiratory function, it is not specifically required for measuring the respiratory rate. The key is to ensure the client is comfortable and able to breathe easily.
B. Have the client rest an arm across the abdomen:
Placing the arm across the abdomen is not a standard practice for measuring respiratory rate. The key is to allow the client to breathe naturally, and this position is not necessary for accurate measurement.
C. Observe one full respiratory cycle before counting the rate:
This ensures that the count is accurate and reflective of the client's typical breathing pattern.
D. Count the rate for 30 seconds if it is irregular:
When measuring the respiratory rate, it is generally recommended to count for a full minute to obtain an accurate representation of the client's breathing pattern. Counting for 30 seconds may underestimate or overestimate the rate, especially if the irregularity is not consistent.
E. Count and report any sighs the client demonstrates:
Sighs can be indicative of emotional or physiological stress, and noting them is important for a comprehensive respiratory assessment.
Correct Answer is A
Explanation
A. Validate the finding:
Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.
B. Document the finding:
Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.
C. Inform the surgeon:
If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.
D. Inform the charge nurse:
Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.
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