The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

"Let's stop and take your vital signs."

"We can take a break anytime."

"Keep taking deep breathes; you will be okay."

"Let's stop: I have all of the information we need."

Answer and Explanation

The Correct Answer is D

A) "Let's stop and take your vital signs": While taking vital signs can be important, it might not address the immediate discomfort the client is experiencing from the deep palpation. This response may not fully address the need to pause the assessment in light of the client’s discomfort.
B) "We can take a break anytime": Offering a break is considerate, but it does not directly address the immediate situation. If the client is already in significant discomfort, it's more appropriate to stop the procedure entirely if the information gathered so far is sufficient.
C) "Keep taking deep breaths; you will be okay": Encouraging deep breathing may help manage some discomfort, but it doesn’t acknowledge the client's need to stop the procedure or the fact that the assessment may have already provided sufficient information.
D) "Let's stop: I have all of the information we need": Stopping the palpation when the client is experiencing pain or discomfort and when enough information has been obtained is the most appropriate response. It shows sensitivity to the client's pain and prioritizes their comfort, while also acknowledging that the assessment may have achieved its purpose.

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Correct Answer is D

Explanation

A. Angioedema: Angioedema is characterized by deep swelling of the skin and mucous membranes, often caused by allergic reactions. It usually affects areas like the lips, eyes, or throat but does not typically present with vesicular eruptions.
B. Actinic cheilitis: Actinic cheilitis results from chronic sun exposure leading to changes in the lips' texture and color. It typically presents as dry, scaly patches or discoloration, not vesicular eruptions.
C. Angular cheilitis: Angular cheilitis involves inflammation and cracking at the corners of the mouth, often due to fungal or bacterial infection. It does not typically present with vesicular eruptions.

D. Herpes simplex: Herpes simplex virus commonly causes vesicular eruptions on the lips and surrounding skin, known as cold sores or fever blisters. These eruptions are characteristic of the herpes simplex infection and align with the description of vesicular eruptions observed in the client.

A. the tricuspid area. B. Erb's point. C. the mitral area. D. the aortic area.

Correct Answer is D

Explanation

A) The tricuspid area: The tricuspid area is located at the lower left sternal border, around the 4th or 5th intercostal space. It is where the tricuspid valve sounds are best heard, not the area for auscultating the 2nd rib space.
B) Erb's point: Erb's point is located at the left sternal border in the 3rd intercostal space. It is a key area for auscultating both the aortic and pulmonic valves, as well as the mitral and tricuspid valves, but it is not associated with the right 2nd rib space.
C) The mitral area: The mitral area, also known as the mitral valve area, is located at the 5th intercostal space at the midclavicular line on the left side. This area is used for auscultating the mitral valve, not the right 2nd rib space.
D) The aortic area: The right 2nd rib space, also known as the 2nd intercostal space at the right sternal border, is the location where the aortic valve sounds are best auscultated. This area is used to listen to the aortic valve's closure and is the first location for cardiac auscultation.

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The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?

Correct Answer is D

Explanation

The right 2nd rib space is the first location for cardiac auscultation and is also known as:

Correct Answer is D

Explanation

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