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

Peristaltic waves.

Heterogeneous color.

Homogeneous color.

Masses.

Answer and Explanation

The Correct Answer is C

A. Peristaltic waves: Visible peristaltic waves in adults may suggest an intestinal obstruction or other abnormal gastrointestinal motility. These waves might be seen in very thin individuals as slight rippling movements or those with serious digestive tract issues and require further diagnostic evaluation. However, prominent waves are not normal.

B. Heterogeneous color: Uneven or blotchy abdominal skin color may indicate bruising, poor circulation, inflammation, or underlying pathology. Such a finding is not typical and should prompt further assessment to rule out localized or systemic conditions.

C. Homogeneous color: A consistent, uniform skin tone across the abdomen is a normal finding and indicates healthy skin perfusion. This suggests that there is no localized inflammation, bruising, or vascular compromise present during inspection.

D. Masses: Palpable or visible abdominal masses are considered abnormal and can be associated with tumors, hernias, or organ enlargement. The discovery of a mass necessitates further diagnostic tests to determine its cause and clinical significance.

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Correct Answer is D

Explanation

A. Tears of the anal mucosa with old blood around anus: This description aligns more with anal fissures, which are painful tears in the mucosa. Anal fissures typically present with bright red blood and sharp pain during bowel movements and are often associated with pain not a shiny, purple mass.

B. Serosanguineous and purulent exudate from anus: This finding suggests infection or an abscess rather than hemorrhoids. Purulent discharge would indicate pus, which is not characteristic of external hemorrhoids and would require a different diagnostic and treatment approach.

C. Anal mucosa prolapse and loose sphincter tone: While anal mucosa prolapse can occur, the presence of a purple, shiny, protruding mass with dark red blood more accurately describes thrombosed external hemorrhoids rather than mucosal prolapse or incontinence.

D. Dried dark red blood on swollen external hemorrhoids: This is the most accurate documentation. External hemorrhoids can appear as shiny, swollen, purple masses, and dried dark red blood indicates prior bleeding from engorged and irritated veins typical in these hemorrhoids.

A. Ask questions in a vague, nonspecific format. B. Begin with questions that are less sensitive in nature. C. Share personal values to put the client at ease. D. Get the most difficult questions over with first.

Correct Answer is B

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions can lead to unclear or incomplete answers and may confuse the client. A structured, clear, and respectful approach helps establish trust and encourages more honest responses over time.

B. Begin with questions that are less sensitive in nature: Starting with general or less personal questions helps build rapport and comfort with the client. Once trust is established, the client may feel more at ease discussing sensitive topics like family mental health history or personal concerns.

C. Share personal values to put the client at ease: Nurses should maintain professional boundaries during assessments. Sharing personal values may introduce bias or shift focus from the client’s needs and feelings, making it harder for them to open up.

D. Get the most difficult questions over with first: Jumping into sensitive or emotionally charged questions too early may make the client feel threatened or uncomfortable, especially if the topic is already distressing. A gradual approach helps promote openness and trust.

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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

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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