The nurse is caring for a client who is admitted to the medical-surgical unit for gastrointestinal disorders. While conducting a focused assessment, the nurse prepares to lightly palpate the client's abdomen. Which part of the hand should the nurse use?

Dorsal surface of the hand.

Fingertips and palmer surface of the fingers.

Palmer surface of the fingers.

Finger pads.

Answer and Explanation

The Correct Answer is D

A. The dorsal surface of the hand is used for assessing temperature, not palpation.

B. The fingertips and palmar surface are used for deep palpation, not light palpation.

C. The palmar surface of the fingers can be used, but the finger pads provide more sensitivity for light palpation, especially when assessing the abdomen.

D. Finger pads are the best part of the hand for light palpation as they allow the nurse to assess tenderness and abdominal consistency accurately.

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Correct Answer is D

Explanation

A. Recommending a psychiatric consult is premature and not appropriate for routine anxiety during an assessment.

B. Starting with invasive aspects may increase the client's anxiety. Instead, the nurse should ease the client into the exam.

C. Staying with the client at all times may not be necessary and could make the client feel more uncomfortable.

D. Using a relaxed manner and reassuring the client can help reduce anxiety and make the physical assessment more comfortable.

A. Stage III B. unstageable C. necrotic stage I D. stage II

Correct Answer is B

Explanation

A. Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B. The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C. The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

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The nurse is caring for a client who is admitted to the medical-surgical unit for gastrointestinal disorders. While conducting a focused assessment, the nurse prepares to lightly palpate the client's abdomen. Which part of the hand should the nurse use?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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