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 ["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.
Correct Answer is A
Explanation
A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.
B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.
C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.
D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.
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