During a gastrointestinal assessment, the nurse detects rebound tenderness in the right lower quadrant (RLQ). What does this finding most likely indicate?

Choice A reason: Providing a blueprint for patient-centered care describes the nursing process (assessment, diagnosis, planning, implementation, evaluation), guiding systematic care delivery. This is integral, unlike prescribing medications, a physician’s role. Assuming this is not part risks misunderstanding the process, critical for structured, effective nursing care in complex patient scenarios.

Choice B reason: Holistic care enhancing outcomes is central to the nursing process, addressing physical, emotional, and social needs through its steps. This contrasts with prescribing, which is medical. Assuming this is not part misaligns with the process’s purpose, risking fragmented care and reduced effectiveness in patient-centered nursing practice.

Choice C reason: A problem-solving approach for complex clients defines the nursing process, using data to address multifaceted needs systematically. Unlike prescribing, it’s a nursing responsibility. Assuming this is not part undermines the process’s role, risking ineffective care planning and interventions critical for managing complex patient conditions in clinical settings.

Choice D reason: Developing medication prescriptions is a physician’s role, not part of the nursing process, which focuses on assessment, diagnosis, planning, implementation, and evaluation. Nurses administer or educate about medications but don’t prescribe. This distinction ensures role clarity, preventing scope-of-practice errors and supporting collaborative, patient-centered care in healthcare settings.

Choice A reason: Percussion involves tapping to assess underlying structures, commonly used for lung or abdominal assessments. In breast assessment, it is not relevant, as it cannot evaluate tissue density or detect masses. Breast examination relies on visual inspection and palpation to identify abnormalities like lumps or skin changes, making percussion inappropriate.

Choice B reason: Inspection is a critical technique in breast assessment, involving visual examination for asymmetry, skin changes, nipple discharge, or dimpling. It precedes palpation to identify visible abnormalities. This method is non-invasive and essential for detecting early signs of breast conditions, such as cancer, aligning with standard clinical protocols for thorough evaluation.

Choice C reason: Doppler ultrasound assesses blood flow, often used in vascular or fetal monitoring, but is not standard for breast assessment. Breast examination uses inspection and palpation, with imaging like mammography for deeper evaluation. Doppler’s role in breast care is limited to specialized diagnostics, not routine physical assessments, making it an incorrect choice.

Choice D reason: Sterile gloves are used for invasive procedures like wound care, not routine breast assessments, which require clean gloves for palpation. Inspection and palpation are primary techniques, and sterile conditions are unnecessary unless performing a biopsy. This choice does not align with standard breast examination practices.