The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Notify the healthcare provider of the rebound tenderness.

Obtain a prescription to catheterize the client's bladder.

Offer to administer a laxative prescribed for PRN use.

Instruct the client in distraction and relaxation techniques.

Answer and Explanation

The Correct Answer is A

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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Correct Answer is D

Explanation

A) Review the client’s serum electrolyte:
While electrolyte imbalances can cause various neurological symptoms, including paresthesia, reviewing serum electrolytes may not directly identify additional findings consistent with the client's paresthesia. It is essential to assess electrolytes for overall health status but may not immediately address the client's reported symptoms.

B) Check distal phalanges capillary refill:
Assessing capillary refill is important for evaluating peripheral circulation and tissue perfusion, but it may not provide direct information about the client's paresthesia. Capillary refill primarily assesses vascular function rather than neurological symptoms like paresthesia.

C) Observe skin for erythema, edema, and warmth:
Observing the skin for signs of inflammation, such as erythema, edema, and warmth, is essential for assessing possible causes of paresthesia, such as inflammation or injury. However, it may not directly identify additional findings consistent with the client's reported paresthesia.

D) Evaluate client's muscle strength and hand grips:
Assessing muscle strength and hand grips can provide valuable information about neurological function and may reveal additional findings consistent with the client's paresthesia. Weakness or changes in muscle strength may accompany paresthesia, indicating potential neurological involvement. Therefore, evaluating muscle strength and hand grips is a crucial action to assess the extent and impact of the client's symptoms.

A. Cardiac atrophy. B. Cardiac enlargement. C. Benign variation. D. Expected finding. E. None F. None

Correct Answer is B

Explanation

Answer: B. Cardiac enlargement.

Rationale:

A) Cardiac atrophy:
Cardiac atrophy refers to the reduction in the size of the heart muscles and is not typically detected through percussion. It would present differently, likely through imaging or echocardiography, rather than an increase in the area of dullness during percussion.

B) Cardiac enlargement:
Percussion revealing dullness extending from the 5th left intercostal space upward to the 2nd left intercostal space suggests an increase in the size of the heart. This pattern indicates cardiac enlargement, as the heart’s borders have extended beyond their typical boundaries, which are usually confined to the 5th left intercostal space along the midclavicular line.

C) Benign variation:
A benign variation would not typically cause such a significant change in the area of cardiac dullness. This finding is more concerning for pathology, such as cardiomegaly, than a harmless variation.

D) Expected finding:
The normal borders of the heart should not extend upward to the 2nd left intercostal space during percussion. This finding is not within normal limits and suggests an abnormal enlargement of the heart, rather than an expected physiological outcome.

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The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

Correct Answer is D

Explanation

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Correct Answer is B

Explanation

Rationale:

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