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 C

Explanation

A. Capillary refill less than 3 seconds: This is considered a normal finding, indicating good peripheral perfusion. It does not correlate with clubbing, which is typically a chronic sign of systemic hypoxia rather than acute perfusion issues.

B. 3+ peripheral dependent edema: Edema is often associated with heart failure or venous insufficiency, not necessarily with clubbing. While both can occur in cardiopulmonary conditions, edema is not a direct indicator or cause of nail clubbing.

C. Oxygen saturation of 85%: This value is significantly low and indicates chronic hypoxemia, which is strongly associated with clubbing of the fingers or toes. Chronic low oxygen levels, as seen in conditions like COPD or congenital heart disease, stimulate tissue changes that result in clubbing.

D. Absent deep tendon reflexes: This finding is typically associated with neurological conditions such as peripheral neuropathy or spinal cord injury., not with hypoxia or diseases causing clubbing. It does not have a physiologic link to nailbed changes.

A. Periumbilical pain localizing to right lower quadrant. B. Anorexia a progressing to nausea, vomiting, and fever. C. Diffuse abdominal pain with elevated neutrophil count. D. Sudden onset of severe anxiety, fear, and concern.

Correct Answer is A

Explanation

A. Periumbilical pain localizing to right lower quadrant: This is a classic sign of appendicitis. The pain typically begins near the umbilicus and later migrates to the right lower quadrant (McBurney's point) as the inflammation progresses and irritates the parietal peritoneum. This localized pain pattern is a strong clinical indicator of appendicitis.

B. Anorexia progressing to nausea, vomiting, and fever: While these are common associated symptoms of appendicitis, they are nonspecific and can be seen in many gastrointestinal conditions such as gastroenteritis. Alone, they are not as definitive as localized right lower quadrant pain in confirming the diagnosis.

C. Diffuse abdominal pain with elevated neutrophil count: Diffuse abdominal pain suggests a more widespread issue, not the localized inflammation typically seen in early appendicitis. An elevated neutrophil count can suggest infection or inflammation but does not pinpoint appendicitis specifically without more localized symptoms.

D. Sudden onset of severe anxiety, fear, and concern: These symptoms may suggest a psychiatric or stress-related condition, or even a cardiac event in some cases, but they are not characteristic of appendicitis and do not support the suspicion of appendicitis.

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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

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is C

Explanation

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Correct Answer is A

Explanation

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