During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Initiate NPO status.

Restrict activity to bed rest.

Monitor urinary output.

Obtain an electrocardiogram.

Answer and Explanation

The Correct Answer is A

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

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Correct Answer is D

Explanation

A. Number of blood clots expelled with each stool:
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does. Therefore, although it may be noted, it is not the most crucial aspect to document initially.

B. Evidence of internal hemorrhoids:
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding, so a comprehensive assessment of the stool is necessary.

C. Unique odor noted with gastrointestinal bleeding:
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool, which can help identify potential causes of bleeding.

D. Color characteristics of each stool:
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract. Describing the color, consistency, and presence of any abnormal substances in the stool helps healthcare providers assess the severity and potential causes of the bleeding.

A. Suggest that the client schedule a mammogram after her next menstrual period. B. Explain to the client that an ultrasound of the breast will likely be necessary. C. Assure the client that her breasts are normal, and advise annual evaluations. D. Request a return visit after her menstrual period for a breast exam re-check.

Correct Answer is C

Explanation

Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.

Rationale:

A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.

B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.

C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.

D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.

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During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When evaluating a client's rectal bleeding, which findings should the nurse document?

Correct Answer is D

Explanation

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Correct Answer is C

Explanation

Rationale:

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