During palpation of a client’s abdomen, the nurse feels a pulsating mass in the midline near the umbilicus. What should the nurse do next?
Continue palpating to assess the size and shape of the mass
Ask the client about their elimination patterns
Measure the abdominal girth for documentation
Notify the healthcare provider immediately
The Correct Answer is D
The presence of a pulsating midline mass is a pathognomonic sign of an Abdominal Aortic Aneurysm (AAA). Deep palpation of such a mass is strictly contraindicated, as mechanical pressure could precipitate an acute aneurysmal rupture, leading to catastrophic internal exsanguination; therefore, immediate surgical or medical consultation is the only appropriate clinical intervention.
A. The nurse must stop palpating immediately. Continuing to palpate a pulsating mass increases the risk of rupturing a potential aortic aneurysm. This is a medical emergency where further manual manipulation of the abdomen can lead to rapid hemodynamic collapse and death due to massive internal hemorrhage.
B. While elimination patterns are part of a general abdominal assessment, they are irrelevant in the context of a pulsating mass. The immediate priority is the potential vascular emergency, and questioning the client about bowel movements delays the necessary medical notification required for life-saving diagnostic imaging and intervention.
C. Measuring abdominal girth may be useful for tracking ascites, but it does not address the acute risk posed by a pulsating arterial mass. The priority is not documentation of size via tape measure, but rather the prevention of rupture and the immediate involvement of the surgical or medical team.
D. Notifying the healthcare provider immediately is the correct priority action. A pulsating mass suggests an aneurysm of the abdominal aorta. The nurse should also monitor the client's vital signs for hypotension and tachycardia, which could indicate that the aneurysm is beginning to leak or rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A focused respiratory assessment is triggered by abnormal findings that suggest impaired gas exchange or airway obstruction. The detection of adventitious sounds, such as crackles, wheezes, or rhonchi, indicates a pathological change in the tracheobronchial tree, necessitating a more detailed investigation into the patient’s pulmonary status and clinical stability.
A. Symmetrical chest expansion is a normal finding during a physical examination. It indicates that both lungs are inflating equally and that there is no obvious pleural effusion, pneumothorax, or localized obstruction preventing air entry. Because it is an expected normal finding, it does not mandate a focused exam.
B. Adventitious breath sounds, such as wheezing (indicating narrowed airways) or crackles (indicating fluid in the alveoli), are abnormal. Their presence requires the nurse to perform a focused assessment, including checking oxygen saturation, assessing for use of accessory muscles, and identifying the exact location and nature of the sounds.
C. A respiratory rate of 16 breaths per minute falls within the normal adult range of 12 to 20 breaths per minute. Since the rate is stable and within expected physiological limits, it does not indicate the need for a focused or emergency respiratory evaluation beyond standard routine monitoring.
D. Vesicular breath sounds are the normal, soft, low-pitched sounds heard over the majority of the lung periphery during auscultation. Hearing these sounds indicates that air is moving freely through the smaller airways and alveoli. As a normal finding, they do not trigger a focused respiratory investigation.
Correct Answer is D
Explanation
Reasoning:
Dermatological assessment relies on the identification of atypical morphologies that may indicate underlying malignancy or systemic disease. The presence of asymmetrical or irregular borders in a pigmented lesion is a significant clinical marker for melanocytic transformation, requiring a detailed evaluation using the ABCDE criteria to rule out malignant melanoma.
A. Even pigmentation is a normal and expected finding during a skin assessment. It indicates that melanin is distributed uniformly and that there are no underlying vascular or inflammatory issues causing localized discoloration, such as vitiligo, cyanosis, or jaundice, which would require further clinical investigation.
B. A smooth texture of the skin is an indicator of health and proper hydration. It suggests that the integumentary system is intact and that there are no abnormal keratinization processes, fungal infections, or inflammatory conditions like eczema or psoriasis that would create a rough or scaly surface.
C. The absence of lesions is the baseline finding for a healthy adult. This means the skin is free from primary lesions like macules or papules and secondary lesions like ulcers or crusts. This finding confirms the integrity of the skin as a protective barrier against environmental pathogens.
D. A new mole with irregular borders is a suspicious finding that requires immediate further investigation. Irregularity in the edges of a nevus is one of the key warning signs of skin cancer. The nurse must document the size, color, and shape and report it for a potential biopsy.
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