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?

Palpate the area for masses.

Ask about recent abdominal trauma.

Document the normal finding.

Observe the midline for scarring.

Answer and Explanation

The Correct Answer is C

A. Palpate the area for masses. Palpating for masses is important but is not specifically indicated by the observation of a depressed umbilicus.

B. Ask about recent abdominal trauma. Asking about trauma can be important but is not directly related to the finding.

C. Document the normal finding. This is the best choice because a depressed umbilicus is a normal variation and does not typically indicate pathology.

D. Observe the midline for scarring. Observing for scarring can be part of the assessment but is not directly indicated by the finding of a depressed umbilicus.

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Correct Answer is B

Explanation

A. Rigidity and firmness. This is not typically expected; rigidity and firmness may indicate muscle spasm or guarding.

B. Sharp, severe pain. This is expected with pyelonephritis, as percussion over the inflamed kidney will elicit pain.

C. Rebound tenderness. Rebound tenderness is more indicative of peritoneal irritation rather than pyelonephritis.

D. Audible thud without pain. This is a normal finding; absence of pain does not align with the expected findings in pyelonephritis.

A. Note the client's responses during the initial interview. B. Ask the client to complete a common proverb or saying. C. Listen while the client reads items listed on the menu. D. Have the client repeat a phrase containing alliteration.

Correct Answer is A

Explanation

A. Note the client's responses during the initial interview. This allows the nurse to observe the client's natural speech patterns in a conversational context, which is a realistic and comprehensive way to assess speech.

B. Ask the client to complete a common proverb or saying. This approach assesses the client's understanding and familiarity with language but may not comprehensively evaluate speech patterns.

C. Listen while the client reads items listed on the menu. This tests reading ability and articulation but may not reflect the client’s natural speech patterns during conversation.

D. Have the client repeat a phrase containing alliteration. This can help assess speech articulation and clarity but is not comprehensive for evaluating overall speech patterns.

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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

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Correct Answer is A

Explanation

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