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. Ask if the client often feels weak or hungry: While important in overall diabetes assessment, weakness or hunger are more related to poor glucose control and they do not specifically indicate peripheral vascular changes such as shiny skin and hair loss.

B. Compare the range of motion of both legs: Assessing range of motion can be useful in evaluating joint or muscular issues but does not provide specific information about vascular status or circulation, which is the primary concern here.

C. Measure the client's capillary glucose: Blood glucose levels are essential in managing diabetes but do not assess the presence or severity of peripheral vascular disease, which can lead to changes in skin and hair growth on the lower legs.

D. Palpate the client's dorsalis pedis pulses: Shiny skin and hair loss on the legs suggest poor peripheral circulation, often related to peripheral arterial disease, a common complication of diabetes mellitus. High blood sugar levels can damage blood vessels over time, leading to narrowing and reduced blood flow, particularly in the lower extremities. Palpating dorsalis pedis pulses helps assess arterial blood flow and supports evaluation of vascular insufficiency.

A. Likely onset of Parkinson's disease. B. Need for a walker to aid in ambulation. C. Expected results for an older adult. D. Increased risk for falling.

Correct Answer is D

Explanation

A. Likely onset of Parkinson's disease: The Tinetti assessment evaluates gait and balance in older adults to identify those at an increased risk of falling but is not diagnostic for Parkinson’s disease. While Parkinson’s can affect gait and balance, a low score alone does not confirm its presence and further neurological evaluation would be necessary.

B. Need for a walker to aid in ambulation: A low Tinetti score may lead to recommending assistive devices like a walker, but the test itself doesn’t directly indicate the need for one. A comprehensive mobility and safety assessment is needed before prescribing mobility aids.

C. Expected results for an older adult: Although balance and gait may decline with age, a combined Tinetti score of 20 (balance 12 + gait 8) is considered low and indicates a significant deviation from safe functional mobility in older adults, rather than an expected finding.

D. Increased risk for falling: A Tinetti total score below 19 suggests a high risk for falls. This client’s score of 20 is just above that critical threshold but still considered moderate risk, clearly indicating impaired mobility and a heightened risk of falling.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is D

Explanation

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

Correct Answer is D

Explanation

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