During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

Ask about recent abdominal trauma.

Observe the midline for scarring.

Document the normal finding.

Palpate the area for masses.

Answer and Explanation

The Correct Answer is C

A) Ask about recent abdominal trauma:
While abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen. Additionally, without further evidence or symptoms suggestive of trauma, it may not be necessary to immediately inquire about recent abdominal trauma.

B) Observe the midline for scarring:
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions. However, the presence of a depressed umbilicus below the surface of the abdomen does not necessarily indicate scarring or previous surgery.

C) Document the normal finding:
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

D) Palpate the area for masses:
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation. In the absence of other concerning findings, it may be unnecessary and potentially uncomfortable for the client to perform palpation based solely on the observation of a depressed umbilicus.

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Correct Answer is B

Explanation

Answer: B. Place the dorsum of the hand on the client's forehead.

Rationale:

A) Ask the client to describe any other related symptoms.
While asking the client about symptoms related to fever, such as chills or sweating, can provide useful subjective information, it is not a reliable or objective method to confirm fever. Direct temperature measurement is needed for confirmation.

B) Place the dorsum of the hand on the client's forehead.
Placing the dorsum (back) of the hand on the client’s forehead is a common method to assess skin temperature. While this action provides a quick, non-invasive estimation of whether the client feels warm, it still requires confirmation with an actual temperature measurement using a thermometer for an objective assessment.

C) Use both hands to hold and palpate the client's hands.
Palpating the client's hands may provide information about extremity temperature or circulation, but it is not a reliable method for assessing core body temperature or confirming the presence of fever.

D) Lightly pinch a fold of skin over the client's sternum.
Pinching a fold of skin over the sternum assesses skin turgor, which is a measure of hydration and elasticity, not temperature. It does not provide any indication of whether the client has a fever.

A. Expected finding. B. Cardiac enlargement. C. Benign variation. D. Cardiac atrophy. E. None F. None

Correct Answer is B

Explanation

B. Cardiac enlargement:
This is the most likely interpretation of the findings. A significant area of dullness across a larger portion of the chest, as described, suggests that the heart is enlarged (cardiomegaly). Enlargement of the heart may result from various conditions, such as heart failure, hypertension, or valvular disease, leading to increased cardiac size and the shift in the percussion borders. This could indicate that the heart has expanded beyond its normal anatomical limits, and further assessment, such as imaging, would be necessary to confirm the diagnosis.

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During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

Correct Answer is B

Explanation

Rationale:

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

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