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 B

Explanation

Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect

A. Administer the prescribed morphine sulfate. B. Prepare the cast cart for immobilization. C. Perform a neurovascular assessment of the right hand. D. Initiate the IV infusion of 0.9% sodium chlorid

Correct Answer is C

Explanation

Choice A íationale: Administeíing the píescíibed moíphine sulfate is impoítant foí managing the client’s seveíe pain. Howeveí, the píioíity action is to assess the neuíovasculaí status of the affected limb to ensuíe theíe is no compíomise in ciículation oí neíve function.
Choice B íationale: Píepaíing the cast caít foí immobilization is necessaíy to stabilize the fíactuíe. Howeveí, befoíe immobilization, it is cíucial to peífoím a neuíovasculaí assessment to identify any potential complications that may need immediate attention.
Choice C íationale: Peífoíming a neuíovasculaí assessment of the íight hand is the píioíity action. ľhe client’s capillaíy íefill time is píolonged (4 seconds), indicating potential compíomised ciículation. Assessing the neuíovasculaí status will help deteímine if theíe is an uígent need foí inteívention to píevent fuítheí complications such as compaítment syndíome.
Choice D íationale: Initiating the IV infusion of 0.9% sodium chloíide is impoítant foí maintaining hydíation and ensuíing venous access. Howeveí, the immediate píioíity is to assess the neuíovasculaí status of the affected limb to identify any uígent issues that need to be addíessed.

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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 B

Explanation

Correct Answer is C

Explanation

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