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

Explanation

Choice A rationale
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts provides a clear and direct approach to obtaining accurate information about the client’s substance use. This method helps in identifying potential health risks and planning appropriate care.
Choice B rationale
Using the term “illegal” or “illicit” to describe street drugs may cause the client to feel judged or defensive, which can hinder open communication. It is better to ask about specific substances directly.
Choice C rationale
Allowing the client to decline answering social questions may result in incomplete health history, which can affect the quality of care provided. It is important to encourage clients to share relevant information while ensuring confidentiality.
Choice D rationale
Obtaining a drug urine screen to verify the legitimacy of the client’s stated history is not an appropriate initial assessment technique. Trust and rapport should be established first through direct questioning.

A. Document the presence of borborygmi. B. Auscultate the remaining quadrants. C. Elevate the head of the client’s bed immediately. D. Use the bell of the stethoscope to auscultate again.

Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

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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 is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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