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?

Nothing by mouth.

Electrocardiogram.

Monitor urinary output.

Complete bed rest.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis). Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

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Correct Answer is C

Explanation

Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.

A. Number of attempts to quit smoking. B. Packs of cigarettes smoked per day. C. Client's current age. D. Number of years the client smoked. E. Age when the client started smoking.

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

Explanation

Choice A Reason

Number of attempts to quit smoking is incorrect. While the number of attempts to quit smoking may provide insight into the client's smoking cessation efforts and motivation, it is not directly relevant to calculating smoking pack years. Pack years specifically quantify the amount and duration of smoking, rather than cessation attempts.

Choice B Reason:

Packs of cigarettes smoked per day is correct. The number of packs of cigarettes smoked per day is a crucial factor in calculating smoking pack years. Pack years are calculated by multiplying the number of packs smoked per day by the number of years the individual has smoked. This information provides a quantitative measure of smoking exposure over time.

Choice C Reason:

Client's current age is incorrect. While the client's current age may be relevant in assessing overall health, risks associated with smoking and in discussing smoking cessation strategies, it is not directly used in the calculation of smoking pack years. Pack years are based on the total duration of smoking and the average daily consumption of cigarettes, not the client's current age.

Choice D Reason:

Number of years the client smoked is correct. The number of years the client has smoked is a critical piece of information for calculating smoking pack years. Pack years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. This helps quantify the duration of smoking history.

Choice E Reason:

Age when the client started smoking is correct. Knowing the age at which the client started smoking is essential for determining the duration of smoking history, which is a key component in calculating pack years. It helps provide a comprehensive understanding of the client's smoking habits and exposure to tobacco smoke over time.

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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

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

When obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. Which information should the nurse obtain for this calculation? Select all that apply.

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

Explanation

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