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 C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

A. "Do you take painkillers like aspirin on a regular basis?" B. "Are you currently taking vitamin supplements?" C. "Do you tend to eat foods that are quite high in fat?" D. "Do you feel like you're able to accept the stress in your life?"

Correct Answer is A

Explanation

A. Asking about regular painkiller (NSAID) use is correct because nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen are a major risk factor for peptic ulcer disease. They can damage the gastric mucosa and increase acid production, leading to ulcer formation.
B. Vitamin supplements are not a common cause of peptic ulcer disease. While some supplements can cause gastrointestinal discomfort, they are not a primary risk factor.
C. High-fat foods can contribute to acid reflux or indigestion but are not a direct cause of peptic ulcers. Peptic ulcer disease is primarily linked to Helicobacter pylori infection and NSAID use.
D. Stress was once thought to be a major cause of ulcers, but current research indicates that it plays a minor role compared to factors like H. pylori infection and NSAID use.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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