Six days following a minor vehicle crash, an older client returns to the emergency department to have stitches removed. While the nurse is removing the stitches, the client reports feeling bloated and not having a bowel movement since the accident. Which intervention should the nurse implement first?

Increase fiber in diet and add daily prune juice.

Perform a digital examination for fecal impaction.

Assess type and frequency of physical activities.

Check bowel sounds and abdominal tenderness.

Answer and Explanation

The Correct Answer is D

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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Correct Answer is B

Explanation

A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.

B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.

C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.

D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. B. Since this client has only a small area of crepitus, it probably is not a significant finding. C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately.

Correct Answer is C

Explanation

A. Trapped subcutaneous air causing crepitus will be absorbed, so the finding is not significant. While trapped air can be absorbed, crepitus can indicate underlying issues such as a pneumothorax or other trauma, so it should not be dismissed as insignificant.

B. Since this client has only a small area of crepitus, it probably is not a significant finding. The size of the area does not necessarily correlate with the severity of the underlying condition. Even a small area of crepitus should be investigated.

C. Crepitus is always abnormal and should be followed-up with a more detailed assessment. This is the most accurate interpretation. Crepitus indicates the presence of air in the subcutaneous tissues, which is always abnormal and warrants further investigation.

D. Since a fractured rib often creates crepitus, a chest x-ray should be scheduled immediately. While a chest x-ray can be part of the assessment, stating that a fractured rib "often" creates crepitus might be misleading. Crepitus can arise from other conditions, and a thorough assessment is needed before determining the exact cause.

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Naxlex Comprehensive Predictor Exams

Which method is best for the nurse to use in determining early development of ascites?

Correct Answer is B

Explanation

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

Correct Answer is C

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?

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?