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 B

Explanation

Answer: B. Wandering behavior with flat affect.

Rationale:

A. Ambulatory and disoriented to place:
This documentation suggests that the client is physically able to walk but does not adequately capture the behavioral aspect of the observation. While the client may be ambulatory, merely stating disorientation does not convey the lack of engagement or emotional response, which is crucial in understanding the client's mental state and overall condition.

B. Wandering behavior with flat affect:
This option accurately reflects the observed behavior of the client. "Wandering behavior" captures the aimless walking, while "flat affect" describes the lack of emotional expression indicated by the blank stare. This documentation provides a clearer picture of the client's mental status, which is vital for further assessment and intervention.

C. Appears confused and depressed:
While confusion may be a relevant aspect of the client's condition, this statement lacks specificity regarding the observed behaviors. Depression cannot be accurately concluded from the blank expression alone, as it may not reflect sadness or mood but rather a cognitive or perceptual issue. More objective descriptors would enhance the clarity of the documentation.

D. Demonstrates signs of early dementia:
This option makes a definitive statement about the possibility of early dementia without sufficient evidence from the observation. While aimless walking and a blank expression can be associated with cognitive decline, diagnosing dementia requires comprehensive assessment and evaluation beyond a single observation. This phrasing could mislead healthcare providers regarding the client’s condition and may lead to premature conclusions about the client’s cognitive health.

A. Dimpled area above anus. B. Flap of tissue at sphincter. C. Increased pigmentation and coarse skin. D. Hypotonic tone of the anal sphincter.

Correct Answer is C

Explanation

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

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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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