A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Lithotomy

Dorsal recumbent

Sim's position

Prone

Answer and Explanation

The Correct Answer is B

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

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Correct Answer is D

Explanation

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

A. In the left lower quadrant. B. At the symphysis pubis. C. In the right upper quadrant. D. Above the umbilicus.

Correct Answer is B

Explanation

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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A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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