The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Firm mass palpated at bottom of left rib cage.

Rebound tenderness with compression over right upper quadrant.

Tip of spleen palpable when client is asked to forcefully exhale.

Pain noted when palpating McBurney's point.

Answer and Explanation

The Correct Answer is A

A.   A firm mass palpated at the bottom of the left rib cage can indicate an enlarged spleen, which is an abnormal finding. Splenomegaly may occur due to various conditions, including infections, liver disease, or blood disorders.
B.   Rebound tenderness in the right upper quadrant is indicative of potential inflammation or irritation in the abdominal cavity, often associated with appendicitis or other conditions affecting the right lower quadrant. This finding is not specific to the spleen but rather to the general abdominal assessment and does not indicate an abnormal response related to spleen palpation.
C.   Normally, the spleen is not palpable in most people. However, if the spleen is slightly enlarged, its tip may be palpable during deep palpation or when the client is asked to exhale forcefully. While this can be an abnormal finding, it may still fall within a range of normal variability depending on the clinical context.
D.   McBurney's point is located in the right lower quadrant of the abdomen and is associated with the appendix. Pain at this location is indicative of potential appendicitis, not an abnormal finding related to spleen palpation. This finding does not provide information about the condition of the spleen.

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Correct Answer is D

Explanation

A. Contractures of the 4th and 5th fingers are more indicative of ulnar nerve involvement, not median nerve compression. Carpal tunnel syndrome primarily affects the thumb, index finger, middle finger, and part of the ring finger. Thus, asking about contractures of the 4th and 5th fingers would not provide useful information about carpal tunnel syndrome.
B. This technique is used to assess the patency of the radial and ulnar arteries, commonly referred to as the Allen test. It is used to evaluate blood flow in the hand, particularly before performing procedures that may impact arterial circulation. This test is not specific to carpal tunnel syndrome and does not provide useful information about median nerve compression.
C. While comparing the hands bilaterally for various signs can be useful in assessing general hand function and circulation, this method does not specifically target the symptoms or diagnostic tests associated with carpal tunnel syndrome. It provides a broad overview but is not specific enough to confirm CTS.
D. This technique is known as the Phalen’s test, which is specifically used to assess for carpal tunnel
syndrome. During the Phalen’s test, the client is asked to flex their wrists and hold the position for about 60 seconds. If the client experiences tingling, numbness, or pain in the median nerve distribution (thumb, index, middle finger, and part of the ring finger), it suggests carpal tunnel syndrome.

A. Instruct the client to close both eyes. B. Cover the client with a warmed blanket. C. Darken the client's room environment. D. Measure the client's body temperature.

Correct Answer is A

Explanation

A. Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B. Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C. Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D. Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

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The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

Correct Answer is D

Explanation

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Correct Answer is A

Explanation

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