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.

Observe the midline for scarring.

Ask about recent abdominal trauma.

Document the normal finding.

Answer and Explanation

The Correct Answer is D

Choice A rationale
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.
Choice B rationale
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions, but the presence of a depressed umbilicus does not necessarily indicate scarring or previous surgery.
Choice C rationale
Asking about recent abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, but it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen.
Choice D rationale
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.

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Correct Answer is D

Explanation

A. Inspection of head and neck is observed in a straight alignment without lateral curves: A straight, well-aligned cervical spine is normal and does not indicate a need for further assessment of lifestyle habits.

B. Evaluation of cranial nerve XI (spinal accessory nerve) reveals flexion is maintained against full resistance:This indicates normal strength of the sternocleidomastoid and trapezius muscles, meaning there is no concern related to lifestyle habits.

C. Palpation of the spinous processes and surrounding muscles are non-tender: The absence of tenderness suggests that there is no acute inflammation, injury, or muscle strain, making further lifestyle inquiries unnecessary.

D. Observation of cervical range of motion reveals flexion and extension is 25 degrees:Normal cervical flexion and extension range from 45 to 90 degrees. A limitation to only 25 degrees suggests restricted mobility, which could be due to poor posture, occupational strain, prolonged screen time, or underlying musculoskeletal conditions.

A. Demonstrates signs of early dementia. B. Appears confused and depressed. C. Ambulatory and disoriented to place. D. Wandering behavior with flat affect.

Correct Answer is D

Explanation

Choice A rationale
Demonstrating signs of early dementia involves more than just walking aimlessly and staring blankly. It includes memory loss, difficulty with complex tasks, and changes in personality or behavior.
Choice B rationale
Appearing confused and depressed is a subjective interpretation and does not accurately describe the observed behavior. Documentation should be objective and specific.
Choice C rationale
Ambulatory and disoriented to place is a partial description but does not capture the full extent of the observed behavior, including the blank expression.
Choice D rationale
Wandering behavior with flat affect accurately describes the observed behavior. It is specific and objective, noting both the physical action (wandering) and the emotional state (flat affect)2.

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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

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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