During the abdominal assessment of an adult, the nurse auscultates a bruit in the upper abdomen area just left of the midline. Which action will the nurse next take?
Report the findings immediately.
Document the findings as normal.
Assess for rebound tenderness.
Palpate the area.
The Correct Answer is A
A. Report the findings immediately: A bruit heard in the upper abdomen just left of the midline may indicate turbulent blood flow through the abdominal aorta, suggesting an aneurysm or vascular stenosis. This finding is potentially life-threatening and must be reported promptly for further evaluation.
B. Document the findings as normal: Bruits are not normal findings during abdominal auscultation. Documenting without notifying the healthcare provider could delay necessary diagnostic testing and intervention, increasing the patient’s risk.
C. Assess for rebound tenderness: Rebound tenderness is used to evaluate for peritoneal irritation or appendicitis. It is not an appropriate follow-up when a vascular bruit is detected and would not provide useful information in this context.
D. Palpate the area: Palpation should be avoided when a bruit is auscultated over the abdomen because it could indicate an abdominal aortic aneurysm. Pressure on the area could increase the risk of rupture.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prevalence: Understanding prevalence helps identify how widespread substance use is, but focusing only on statistics does not guide nurses in providing direct interventions or support for clients. Prevalence is important for public health surveillance but not the primary nursing focus in practice.
B. Law Enforcement: Law enforcement addresses the legal aspects of substance use but is not within the nursing scope of care. Nurses may collaborate with justice systems but their role is centered on patient health, not policing.
C. Social Determinants of Health: Social determinants play a significant role in influencing substance use. However, the central role of nurses remains to promote healthier behaviors and prevent complications through health promotion strategies.
D. Health Promotion: Health promotion is the critical nursing focus in substance use, as it involves education, prevention, early intervention, and support for recovery. By empowering individuals and communities, nurses help reduce harm, prevent relapse, and improve overall health outcomes.
Correct Answer is B
Explanation
A. Shiny, pink tympanic membrane: A normal tympanic membrane is typically pearly gray in color, not shiny pink. A pink appearance could suggest inflammation or infection, which would not be considered normal in an older adult.
B. High-tone frequency loss: Presbycusis, the age-related hearing loss, usually begins with difficulty hearing high-frequency sounds such as consonants. This is a common and expected finding in older adults and is considered a normal age-related change.
C. Increased elasticity of the pinna: With aging, the pinna tends to lose elasticity and become more rigid rather than more flexible. Increased elasticity is not characteristic of older adults and would not be considered normal.
D. Thin, translucent membrane: Aging tympanic membranes often become thicker and more opaque, not thinner and translucent. Increased opacity is a typical age-related finding and helps distinguish older tympanic membranes from those of younger adults.
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