A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

In the left lower quadrant.

At the symphysis pubis.

In the right upper quadrant.

Above the umbilicus.

Answer and Explanation

The Correct Answer is B

A. The left lower quadrant contains portions of the small and large intestines but is not the starting point for palpating the bladder.
B. The nurse should begin palpating at the symphysis pubis because the bladder is located in the lower abdomen. When distended, it rises above the pubic symphysis and can extend toward the umbilicus.
C. The right upper quadrant contains the liver and gallbladder but is not relevant to bladder assessment.
D. A significantly distended bladder may extend above the umbilicus, but the nurse should begin palpation at the symphysis pubis and move upward to assess for distention.

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Correct Answer is B

Explanation

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

A. Have the client lay on their left side. B. Ask the client to exhale and hold their breath. C. Encourage the client to raise their head off the pillow. D. Assist the client in flexing their knees.

Correct Answer is D

Explanation

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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A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?