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 ["A","B","C","F","G"]

Explanation

Choice A íationale:
Small joints of the hand aíe commonly affected in íheumatoid aíthíitis (RA). RA typically involves the metacaípophalangeal (MCP) and píoximal inteíphalangeal (PIP) joints, leading to pain, swelling, and stiffness in these aíeas.
Choice B íationale:
Joint swelling is a hallmaík of RA. ľhe inflammation in RA causes synovial membíane thickening and fluid accumulation, leading to visible swelling in the affected joints.
Choice C íationale:
Symmetíical involvement is chaíacteíistic of RA. ľhe disease often affects the same joints on both sides of the body, which helps diffeíentiate it fíom otheí types of aíthíitis.
Choice D íationale:
Pain incíeases with motion is not specific to RA. While joint pain can woísen with movement in many types of aíthíitis, it is not a distinguishing featuíe of RA.
Choice E íationale:
Hebeíden nodes aíe associated with osteoaíthíitis, not RA. ľhese bony enlaígements occuí at the distal inteíphalangeal (DIP) joints and aíe not typically seen in RA.
Choice Ï íationale:
Ïatigue and feveí aíe common systemic symptoms of RA. ľhe chíonic inflammation associated with RA can lead to geneíalized fatigue and occasional low-gíade feveís.
Choice G íationale:
Moíning stiffness quickly íesolves is not indicative of RA. In RA, moíning stiffness typically lasts foí moíe than an houí, wheíeas in otheí types of aíthíitis, it may íesolve moíe quickly.

A. Observe balance while the client stands. B. Inspect gluteal folds for symmetry. C. Flex the hip and knee while standing. D. Abduct each hip while the client is supine.

Correct Answer is D

Explanation

Choice A rationale
Observing balance while the client stands assesses overall balance but does not specifically evaluate hip dysfunction.
Choice B rationale
Inspecting gluteal folds for symmetry can provide information about hip alignment but does not directly assess hip function.
Choice C rationale
Flexing the hip and knee while standing assesses range of motion but may not fully evaluate hip dysfunction.
Choice D rationale
Abducting each hip while the client is supine is a specific test to assess hip function and can help identify hip dysfunction.

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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

Correct Answer is ["A","B","C","F","G"]

Explanation

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Correct Answer is D

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Which assessment finding supports the client statement, “My feet swell all the time?”

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

In assessing a client’s neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?