The nurse knows that the rationale for using deep palpation during an abdominal assessment is to determine which of the following?
Superficial tenderness
Bowel motility
Overall impression of skin surface and superficial musculature
Enlarged organs
The Correct Answer is D
Choice A reason: Superficial tenderness is assessed with light palpation, which evaluates surface sensitivity. Deep palpation probes deeper structures, like organs, and is not primarily for detecting superficial pain, making this an incorrect rationale.
Choice B reason: Bowel motility is assessed via auscultation, which detects bowel sounds, not palpation. Deep palpation evaluates organ size or masses, not dynamic motility, making this an incorrect purpose for the technique.
Choice C reason: The overall impression of skin and superficial musculature is gained through inspection and light palpation. Deep palpation targets deeper structures like organs, not surface characteristics, making this an incorrect rationale.
Choice D reason: Deep palpation is used to assess for enlarged organs, such as hepatomegaly or splenomegaly, by probing deeper abdominal structures. This allows detection of abnormal masses or organ sizes, making this the correct rationale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Simultaneously palpating both carotid arteries is dangerous, risking reduced cerebral blood flow, especially in cardiovascular patients. Using the bell to listen for bruits is safer, so this is incorrect.
Choice B reason: Deep breaths are for lung auscultation, not carotid, where patients hold breath to reduce noise. The bell detects low-pitched bruits, so instructing deep breaths is incorrect for carotid assessment.
Choice C reason: Compressing the carotid artery risks reducing blood flow or dislodging plaques, which is unsafe. Listening with the bell for bruits is the standard method, so this is incorrect.
Choice D reason: Listening with the bell of the stethoscope detects low-frequency bruits, indicating carotid artery narrowing, which is critical in cardiovascular disease. This is the correct technique for safe assessment.
Correct Answer is B
Explanation
Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.
Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.
Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.
Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.
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