A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
Bilateral bowel sounds in lower quadrants
Symmetrical convex sphere shape
Ecchymosis
Concave umbilicus
The Correct Answer is C
A. Bilateral bowel sounds in the lower quadrants are normal and do not require further investigation unless they are abnormal in frequency or tone.
B. A symmetrical convex sphere shape of the abdomen can be a normal finding, especially in a well-nourished individual.
C. Ecchymosis (bruising) may be a sign of trauma, bleeding disorders, or other underlying health conditions that require further investigation.
D. A concave umbilicus may be normal or could indicate a past surgical history or conditions like malnutrition, but it doesn't inherently require investigation unless associated with other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Filing nails in a rounded shape may lead to ingrown nails, so a straight-across filing is recommended for safety and proper nail care.
B. An orange stick is commonly used to clean under the nails, as it is gentle and reduces the risk of injury to the nail bed.
C. Pushing the cuticles back with a metal nail file can cause injury and infection. A soft tool like an orangewood stick is preferred.
D. Trimming the nails at the lateral corners is not recommended as it can cause the nails to become ingrown. Nails should be trimmed straight across.
Correct Answer is B
Explanation
A. Documenting that the nurse was unable to measure the temperature is unnecessary if the nurse can follow the correct procedure of waiting and measuring after a proper interval.
B. The nurse should wait at least 30 minutes after the client has eaten or consumed ice chips before measuring the oral temperature to ensure an accurate reading.
C. Proceeding immediately to measure the temperature after consuming ice chips may result in an inaccurate reading, as it can lower the temperature of the mouth.
D. Providing warm water and waiting 5 minutes may not be sufficient to correct the cooling effect of the ice chips on the oral cavity.
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