A nurse observes the following during the physical exam. How will the nurse document this finding?
Grey-Turner Sign
Steatorrhea
Asterixis
Cullen's Sign
The Correct Answer is D
A. Grey-Turner Sign: Grey-Turner Sign refers to bruising along the flanks, often associated with retroperitoneal hemorrhage or acute pancreatitis.
B. Steatorrhea: Steatorrhea refers to fatty stools that are pale, bulky, and foul-smelling, indicating malabsorption, not a physical exam finding on the skin.
C. Asterixis: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, seen in hepatic encephalopathy, not a skin finding.
D. Cullen's Sign: Cullen's Sign is bruising around the umbilicus, indicating intra-abdominal bleeding, often seen in conditions such as acute pancreatitis or ruptured ectopic pregnancy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Avoid positioning the client supine: Orthopnea is the inability to breathe comfortably while lying flat, so the nurse should avoid placing the client in a supine position and instead elevate the head of the bed.
B. Limit the client's activity level: While activity may need to be adjusted, this is not the primary concern for orthopnea.
C. Administer supplemental oxygen at all times: Oxygen may be necessary, but the key issue with orthopnea is the need to avoid lying flat, not necessarily the need for constant supplemental oxygen.
D. Teach the client deep breathing and coughing exercises: While beneficial for other conditions, this does not directly address orthopnea, which is primarily positional.
Correct Answer is ["B","C","D"]
Explanation
A. Instruct the patient to lie on the Left side: The patient should lie on their right side (the biopsy side) to apply pressure and prevent bleeding.
B. Assess the patient's vital signs: Monitoring vital signs is crucial to detect signs of bleeding, hypovolemia, or shock.
C. Assess the dressing over the puncture site: Checking for bleeding or hematoma formation at the puncture site is important to detect complications.
D. Assess for signs/symptoms of a pneumothorax: A pneumothorax is a possible complication of liver biopsy, especially if the biopsy needle punctures the lung.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today