A nurse is completing an assessment. Which should the nurse assess using inspection?
Murmurs
Bruising and masses
Bowel sounds
Rebound tenderness
The Correct Answer is B
A. Murmurs: Heart murmurs are assessed through auscultation using a stethoscope, not inspection. Listening to heart sounds allows the nurse to detect abnormal blood flow or valvular issues.
B. Bruising and masses: Inspection is the primary method for identifying visible abnormalities such as bruising, skin discoloration, swelling, or masses. Careful observation allows the nurse to note location, size, shape, color, and symmetry.
C. Bowel sounds: Bowel sounds are assessed through auscultation, listening with a stethoscope to determine frequency and quality, not through visual inspection.
D. Rebound tenderness: Rebound tenderness is assessed through palpation, where the nurse applies and releases pressure to detect pain responses in the abdomen, rather than using inspection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine the preferred communication methods with the client: Identifying the client’s preferred methods, such as speaking clearly, using written notes, or adjusting hearing aids, ensures effective communication. This approach promotes accurate information gathering and client engagement during the interview.
B. Put a table between the nurse and the client to take notes: Placing a physical barrier can impede visual and auditory communication cues. Effective communication requires clear sightlines and direct interaction rather than obstacles that may hinder understanding.
C. Ask the client if they can bring a family member to the next visit: While family support can help with communication, the immediate priority is to establish effective communication directly with the client during the current interview, respecting their independence and privacy.
D. Sit in a chair to the side of the client: Sitting to the side may make it difficult for the client to see facial expressions and lip movements, which are important for clients with hearing impairments. Facing the client directly is more effective for clear communication.
Correct Answer is D
Explanation
A. Beneficence: Beneficence involves acting in the client’s best interest to promote well-being and prevent harm. While the provider may have attempted to ensure the client’s safety, allowing the client to leave does not exemplify beneficence because the focus was on respecting the client’s choice rather than prioritizing their safety.
B. Fidelity: Fidelity refers to maintaining loyalty, keeping promises, and being faithful to commitments made to the client. Although the provider provided information and guidance, the scenario emphasizes respect for decision-making rather than maintaining a specific promise or commitment.
C. Veracity: Veracity involves truth-telling and providing accurate, honest information. The healthcare provider did explain the risks associated with leaving, which demonstrates veracity, but the ethical principle highlighted in this situation is about the client’s right to make their own decisions.
D. Autonomy: Autonomy is the ethical principle that supports an individual’s right to make informed decisions about their own care. By respecting the client’s choice to leave despite the risks, the healthcare provider upheld the client’s autonomy.
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