A nurse is preparing to perform palpation during an abdominal assessment of a client. Which describes the purpose of using light palpation?

It reduces the client's anxiety during the assessment

It helps identify areas of tenderness and abnormalities

It is the only technique used for abdominal assessment

It allows for the assessment of the abdominal organs

Answer and Explanation

The Correct Answer is B

A. It reduces the client's anxiety during the assessment: While gentle touch may help the client feel more comfortable, the primary purpose of light palpation is not to reduce anxiety but to gather assessment data. Anxiety reduction is a secondary benefit rather than the main objective.

B. It helps identify areas of tenderness and abnormalities: Light palpation allows the nurse to feel surface characteristics, detect tenderness, and identify abnormalities such as masses or swelling. It is the initial step in palpation before progressing to deeper techniques, providing important information about the abdominal area.

C. It is the only technique used for abdominal assessment: Light palpation is just one technique. Deep palpation and other assessment methods like inspection, percussion, and auscultation are also necessary for a complete abdominal assessment.

D. It allows for the assessment of the abdominal organs: Assessment of deeper abdominal organs requires deep palpation, not light palpation. Light palpation primarily evaluates superficial structures and detects areas that may need further examination.

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Correct Answer is ["D","E","G"]

Explanation

A. Rhinitis of right nare present: This is an observable sign noted by the nurse during assessment, making it objective data.

B. Pulse 110 bpm: Measured using a monitor or palpation, pulse is a quantifiable, objective finding.

C. Temperature 101.8 F (38.7 C): Body temperature is measured with a thermometer, making it objective data.

D. Reports tenderness during palpation of sinus cavities: Tenderness is a sensation reported by the client, reflecting their personal experience, so it is subjective data.

E. Reports light sensitivity: Light sensitivity is reported by the client and cannot be directly measured, making it subjective.

F. Lymphadenopathy >2 cm: Enlarged lymph nodes are assessed and measured by the nurse, making this objective data.

G. History of allergies to pollen, dust, animal dander: The client provides this information, making it subjective data derived from their personal history.

H. Right eye periorbital edema present: Swelling around the eye is observable, measured, and documented by the nurse, so it is objective data.

A. A client who is reporting a severe headache and new vision changes B. A client who requires assistance when transferring to the exam table C. A client who requires a follow-up physical for their medication refill D. A client who is reporting minor swelling and pain in their left foot

Correct Answer is A

Explanation

A. A client who is reporting a severe headache and new vision changes: Sudden severe headache with vision changes may indicate a potentially life-threatening condition such as a stroke, aneurysm, or increased intracranial pressure. This client requires an immediate emergency assessment to prevent serious complications.

B. A client who requires assistance when transferring to the exam table: Needing help with transfers is important for safety but does not indicate an urgent medical condition. This task can be addressed after more critical clients are assessed.

C. A client who requires a follow-up physical for their medication refill: Routine follow-up for prescription refills is non-urgent and can safely be scheduled after emergency or acute cases are addressed.

D. A client who is reporting minor swelling and pain in their left foot: Minor swelling and pain are usually non-life-threatening. While assessment is necessary, it does not require immediate emergency evaluation compared to acute neurological or vision changes.

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A nurse is preparing to perform palpation during an abdominal assessment of a client. Which describes the purpose of using light palpation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

Correct Answer is ["D","E","G"]

Explanation

The nurse is caring for a group of clients. Which client should the nurse plan to complete an emergency assessment on?

Correct Answer is A

Explanation

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The nurse notices that a client is wearing a hearing aid and does not respond to answers promptly. Which action should the nurse take to conduct the interview?

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