The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Review the client's blood work for sodium and bicarbonate levels.

Assess the client for signs and symptoms of peptic ulcer disease.

Assess the client's nutritional status.

Assess the client for other signs and symptoms of liver disease.

Answer and Explanation

The Correct Answer is D

A. Reviewing sodium and bicarbonate levels is not the most immediate action. While these lab values may provide useful information, they do not directly assess the suspected condition.
B. Assessing for peptic ulcer disease is incorrect because a tight, distended abdomen with visible arterioles (caput medusae) is more indicative of liver disease, such as cirrhosis or portal hypertension, rather than a gastric ulcer.
C. Assessing the client’s nutritional status may be important, but it is not the priority in this situation. Malnutrition can be a consequence of liver disease, but the nurse should first focus on identifying the underlying condition.
D. Assessing the client for other signs and symptoms of liver disease is correct. A distended abdomen and visible arterioles suggest possible ascites and portal hypertension, both of which are common in liver disease. Further assessment for jaundice, hepatic encephalopathy, or changes in liver enzyme levels would be appropriate.

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Correct Answer is B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. Understanding of the referral process. B. Recognition of the client's medical prognosis. C. Drawing inferences about the client. D. Knowledge of anatomy and physiology.

Correct Answer is C

Explanation

A. Understanding the referral process is important for coordinating care but is not required to identify abnormal data and client strengths.
B. While knowing the medical prognosis can provide context, the nursing process focuses on holistic client assessment rather than medical diagnosis.
C. Drawing inferences about the client is correct because analyzing the collected data allows the nurse to recognize patterns, identify potential health problems, and determine the client’s strengths.
D. Knowledge of anatomy and physiology is valuable, but interpretation and clinical judgment (drawing inferences) are crucial for identifying abnormal data.

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The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nursing student correctly describes a risk diagnosis by which of the following statements?

Correct Answer is B

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

Correct Answer is C

Explanation

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

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A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?