The nurse completes inspection of the abdomen on an adult client.
Which finding is considered normal for this client?
Masses.
Peristaltic waves.
Homogeneous color.
Heterogeneous color.
The Correct Answer is C
Choice A rationale
The presence of abdominal masses is an abnormal finding during inspection. Masses can indicate tumors, organ enlargement, or other pathological conditions that require further investigation and are not considered a normal anatomical variation.
Choice B rationale
Peristaltic waves, while physiologically present, are typically not visible on inspection of the abdomen in healthy adults. Visible peristaltic waves can indicate increased intestinal motility or obstruction, which are abnormal findings requiring medical evaluation.
Choice C rationale
Homogeneous color, meaning a uniform and consistent skin tone across the abdomen, is considered a normal finding. This indicates healthy skin perfusion and the absence of localized discoloration, inflammation, or other dermatological abnormalities.
Choice D rationale
Heterogeneous color, meaning uneven or varied skin tone, is generally considered an abnormal finding. This could indicate localized areas of hyperpigmentation, hypopigmentation, bruising, rashes, or other dermatological conditions that deviate from normal skin presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Measuring capillary glucose assesses glycemic control, which is important in diabetes management, but it does not directly provide data to support signs of peripheral arterial disease (PAD), such as shiny skin and absent hair growth on the lower legs. These findings are indicative of impaired blood flow, not necessarily immediate glucose levels.
Choice B rationale
Shiny skin and lack of hair on the lower legs in a client with diabetes are classic signs of peripheral arterial disease (PAD), resulting from compromised blood flow due to atherosclerosis. Palpating the dorsalis pedis pulses directly assesses arterial perfusion to the feet, providing crucial objective data to support the presence and severity of PAD. Normal pulse strength is 2+.
Choice C rationale
Asking about weakness or hunger assesses symptoms of hypoglycemia or hyperglycemia, which are metabolic complications of diabetes. While important for overall diabetes management, these symptoms do not directly relate to or provide further data for the observed integumentary changes indicative of compromised peripheral circulation.
Choice D rationale
Comparing the range of motion of both legs assesses musculoskeletal integrity and joint function. While mobility can be affected by diabetic neuropathy or arthropathy, it does not directly provide additional data for the observed changes in skin and hair, which are specifically linked to vascular insufficiency in the lower extremities.
Correct Answer is C
Explanation
Choice A rationale
While a head-to-toe physical assessment is comprehensive, a focused approach is more appropriate for a routine postsurgical evaluation six weeks after a hysterectomy. The primary concern is the client's recovery and any specific issues related to the surgery, making a broad assessment less efficient for this purpose.
Choice B rationale
A Papanicolaou smear is a screening test for cervical cancer, which is not indicated six weeks after a hysterectomy where the cervix has been removed. This procedure is irrelevant to a routine postsurgical evaluation for recovery from the surgical intervention itself.
Choice C rationale
Collecting information about the client's activities since surgery allows the nurse to assess healing, mobility, pain management, and any complications related to the hysterectomy. This targeted approach efficiently gathers relevant data concerning the client's recovery and functional status.
Choice D rationale
A comprehensive review of systems, while thorough, is a broad approach that might not be the most efficient for a routine postsurgical evaluation. Focusing on activities and specific postsurgical concerns provides more pertinent information for assessing recovery and identifying potential complications related to the hysterectomy.
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