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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.
Correct Answer is A
Explanation
A) Asymmetrical shape: One of the key "ABCD" characteristics of malignant melanoma is asymmetry. Melanomas often have an irregular shape where one half does not match the other, unlike benign moles, which are typically symmetrical. This characteristic helps in distinguishing malignant lesions from benign ones.
B) Diameter less than 6mm: Malignant melanomas are often larger than 6 mm in diameter, especially as they progress. While smaller lesions can still be malignant, a diameter less than 6 mm is not a distinguishing feature for melanoma. Typically, melanomas are identified as growing larger over time.
C) Color is uniform: Malignant melanomas usually exhibit multiple colors or uneven pigmentation rather than uniform color. Uniform color is more characteristic of benign moles. Melanomas can show a mix of colors, including shades of brown, black, and sometimes red or white.
D) Borders well demarcated: Malignant melanoma often has irregular, not well-defined borders. The edges of a melanoma are usually uneven or not clearly defined, unlike benign moles, which typically have smooth, well-demarcated borders.
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