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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

While comparing measured circumferences of each extremity joint can provide information on swelling or muscle atrophy, it does not directly assess for asymmetry in leg length, which is the primary concern when legs appear asymmetrical. This measurement is more indicative of fluid accumulation or muscle wasting patterns.

Choice B rationale

Measuring the length of each leg directly quantifies any disparity, providing objective data regarding potential limb length discrepancy. This is crucial for identifying underlying skeletal or muscular issues that could cause asymmetrical appearance and guide appropriate interventions.

Choice C rationale

Observing the client's gait can reveal compensatory mechanisms due to leg length discrepancy, such as a limp or uneven stride. However, gait analysis alone does not definitively confirm or quantify the actual leg length difference, which requires precise measurement.

Choice D rationale

Performing passive range of motion assesses joint mobility and flexibility, but it does not directly measure leg length. While limitations in range of motion might be associated with underlying conditions, they do not specifically address the perceived asymmetry in leg length.

Correct Answer is []

Explanation

Condition: transient ischemic attack
2 actions: compress gently one carotid at a time, perform a full neurological exam
2 parameters: bruit, pulses

Rationale for correct condition
Transient ischemic attack (TIA) is caused by temporary cerebral ischemia, often due to carotid artery stenosis or embolism. The client’s mild disorientation and carotid bruit suggest impaired cerebral blood flow without permanent infarction. TIAs present as transient neurological symptoms resolving within 24 hours, consistent with intermittent confusion. This condition is a warning sign for potential future stroke and requires urgent evaluation. Early identification and intervention can prevent progression to stroke.

Rationale for correct actions
Compressing gently one carotid artery at a time helps assess pulse quality and detect possible vascular occlusion or stenosis while avoiding bilateral compression that can cause cerebral hypoperfusion. Performing a full neurological exam evaluates cognitive function, motor skills, and sensory deficits, identifying areas affected by transient ischemia and guiding further management. Both actions are essential to assess the extent of vascular and neurological involvement accurately.

Rationale for correct parameters
Monitoring the bruit helps track turbulent blood flow through a narrowed carotid artery, indicating worsening stenosis risk. Assessing pulses ensures adequate peripheral circulation and detects any changes from baseline that could signal embolic events. These parameters help evaluate the vascular status and risk of ischemic events continuously.

Rationale for incorrect conditions
Stroke results in permanent neurological deficits, not transient symptoms; the client is alert and only mildly disoriented. Aortic stenosis affects cardiac outflow, not carotid flow, and is unrelated to confusion or carotid bruits. Carotid artery dissection involves vessel wall injury causing acute symptoms like neck pain and ischemia, which the client lacks.

Rationale for incorrect actions
Having the patient lie down is unnecessary and may not improve cerebral perfusion. Administering supplemental oxygen is not indicated without hypoxia. Applying firm bilateral pressure can dangerously reduce cerebral blood flow causing syncope or stroke.

Rationale for incorrect parameters
Distended jugular veins indicate right heart failure, unrelated to carotid disease. Visual acuity changes are more associated with ophthalmic artery issues, not carotid bruits. Chest pain relates to cardiac ischemia, not carotid vascular assessment.

Take home points

transient ischemic attacks are brief episodes of cerebral ischemia without permanent damage
carotid bruits suggest arterial stenosis and increased stroke risk
neurological exams and careful vascular assessment are critical in TIA evaluation
differentiate TIA from stroke, cardiac causes, and carotid dissection for appropriate treatment

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The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is []

Explanation

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The nurse completes inspection of the abdomen on an adult client.
Which finding is considered normal for this client?