The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)
Umbilicus
Midclavicular lines
Sternum
Lower border of the right ribs.
Correct Answer : A
To map the client's abdomen into four quadrants, the nurse should use the umbilicus as the landmark to perform this assessment. The abdomen is divided into four quadrants by drawing an imaginary line from the center of the umbilicus to the pubic symphysis and another line from the center of the umbilicus to the xiphoid process of the sternum. This helps in identifying the location of any potential abdominal discomfort or tenderness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"Pain is whatever the person experiencing it says it is," to include in the orientation. This definition reflects the concept of pain as a subjective experience that cannot be directly observed or measured, but only reported by the individual experiencing it. It emphasizes the importance of believing and acknowledging the patient's report of pain, and not relying solely on objective indicators or assumptions about the cause or intensity of pain. This definition also aligns with current standards of pain assessment and management, which prioritize patient-centered care and the use of self-report measures to guide treatment decisions.
Correct Answer is B
Explanation
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
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