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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Immobile patients are at high risk for developing pressure ulcers due to prolonged pressure on the skin, leading to tissue breakdown.

B. Contractures of the extremities can occur as a result of muscle atrophy and lack of movement in immobilized patients.

C. Immobility increases the risk of venous stasis, leading to the development of deep vein thrombosis (DVT).

D. Crackles in the lungs may result from immobility due to fluid accumulation or atelectasis, particularly in patients who are not moving or changing position frequently.

E. Polyuria is not commonly associated with immobility.

F. Diarrhea is not commonly associated with immobility.

A. The client is able to stick out the tongue midline and side to side. B. The client follows an object with the eyes without nystagmus or strabismus. C. The client has equal strength when moving both shoulders against resistance. D. The client is able to hear normally with the whispered voice test.

Correct Answer is C

Explanation

A. Sticking out the tongue assesses cranial nerve XII (hypoglossal nerve), not XI.

B. Following an object with the eyes assesses cranial nerves III, IV, and VI, not XI.

C. Cranial nerve XI (the accessory nerve) controls the sternocleidomastoid and trapezius muscles, and testing involves shoulder shrugging and head rotation against resistance.

D. Hearing normally assesses cranial nerve VIII (vestibulocochlear nerve).

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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

Naxlex Comprehensive Predictor Exams

A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

While conducting a focused neurological assessment, the nurse includes testing the function of cranial nerve XI in a client. What assessment findings indicate the nerve is intact and functioning?

Correct Answer is C

Explanation

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