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During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

Constipation

Splenomegaly

Distended bladder

Ascites

Answer and Explanation

The Correct Answer is D

A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.

B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.

C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.

D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.

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Correct Answer is D

Explanation

A. Change in cilia: This is not the cause of dry, flaky cerumen. It would not be typical to assess hearing loss based on this observation alone.

B. Poor hygiene: Dry, flaky cerumen is not indicative of poor hygiene. Hygiene-related cerumen would more likely be wet and impacted.

C. Lesions from eczema: While eczema can affect the ear canal, the dry cerumen itself is more likely to be a normal characteristic for some individuals, particularly in people of Asian descent.

D. Normal finding: The presence of dry, flaky cerumen is normal in certain ethnic groups, including East Asians, and usually requires no follow-up.

A. Shield the lips so that the sound is muffled. B. Whisper a set of random numbers and letters, and then ask the patient to repeat them. C. Ask the patient to place his finger in his ear to occlude outside noise. D. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

Correct Answer is B

Explanation

A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.

B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.

C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.

D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.

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During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

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Naxlex Comprehensive Predictor Exams

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding:

Correct Answer is D

Explanation

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is B

Explanation

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