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. Pelvic examination: A pelvic examination is generally used to assess the reproductive organs in females rather than the prostate. It does not provide a direct assessment of the prostate gland in males.
B. Transillumination: Transillumination is a technique used to detect fluid-filled cysts or masses in areas such as the scrotum or breast. It is not used to assess the prostate gland.
C. Bladder percussion: Bladder percussion is used to assess bladder size and fullness, typically to diagnose conditions related to bladder dysfunction. It does not provide information about the prostate.
D. Digital rectal examination: A digital rectal examination (DRE) is the standard method used to assess the size, shape, and consistency of the prostate gland. It allows the clinician to feel the prostate through the rectal wall and is essential for evaluating prostate health.

A. Secondary B. Quaternary C. Tertiary D. Primary

Correct Answer is C

Explanation

A) Secondary: Secondary prevention involves early detection and intervention to manage or treat a disease in its early stages, such as screening for diabetes or monitoring blood glucose levels. Administering insulin does not fall under this category, as it is not about early detection but rather ongoing management.
B) Quaternary: Quaternary prevention focuses on minimizing the harm of medical interventions, avoiding overmedicalization, and improving the quality of life. This type of prevention is more about avoiding unnecessary treatments and ensuring the patient receives appropriate care. Administering insulin is not related to this concept.
C) Tertiary: Tertiary prevention aims to manage and mitigate the effects of an established disease to improve the quality of life and reduce complications. Administering insulin to a client with type 1 diabetes mellitus is an example of tertiary prevention because it is part of managing and treating the chronic condition to prevent complications and maintain health.
D) Primary: Primary prevention focuses on preventing the onset of disease through measures such as vaccination, lifestyle changes, or avoiding risk factors. Administering insulin does not prevent the onset of type 1 diabetes but rather manages an existing condition.

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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

Which of the following would the nurse expect to be done to assess the size of the prostate?

Correct Answer is D

Explanation

A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. Which of the following types of prevention is the nurse demonstrating?

Correct Answer is C

Explanation

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