When assessing a client’s abdomen, the nurse uses auscultation to assess for which possible finding?

Guarding.

Ascites.

Striae.

Bruits.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Guarding refers to voluntary or involuntary muscle contraction of the abdominal wall in response to pain or inflammation. This is assessed through palpation, where the nurse feels for muscle rigidity, not through auscultation, which involves listening to internal sounds.

Choice B rationale

Ascites, the accumulation of fluid in the peritoneal cavity, is primarily detected through inspection (distended abdomen), palpation (fluid wave, shifting dullness), and percussion. Auscultation is not the primary method for identifying the presence of free fluid in the abdominal cavity.

Choice C rationale

Striae, commonly known as stretch marks, are linear streaks or bands on the skin resulting from rapid stretching. These are visual findings, assessed through inspection of the skin surface, and cannot be detected by auscultation, which relies on sound perception.

Choice D rationale

Bruits are abnormal vascular sounds, often described as swishing or humming, produced by turbulent blood flow through a narrowed or dilated artery. Auscultation with a stethoscope is the appropriate technique to detect these sounds over abdominal arteries, indicating potential vascular abnormalities.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

An enlarged, visible lymph node is not a normal finding and requires further investigation. Lymph nodes are part of the immune system and typically are not visible or easily palpable unless they are inflamed or enlarged due to infection, inflammation, or malignancy. Documenting it as normal would be incorrect and delay appropriate assessment.

Choice B rationale

Auscultating a lymph node for a bruit, which is an abnormal vascular sound, is not a standard assessment technique for lymph nodes. Bruits are typically associated with turbulent blood flow in arteries or veins. Lymph node assessment primarily involves palpation for size, consistency, mobility, and tenderness.

Choice C rationale

An enlarged lymph node can be indicative of an inflammatory or infectious process. Asking the client about localized tenderness provides crucial subjective data that can help differentiate between various causes of lymphadenopathy. Tenderness often suggests an acute inflammatory or infectious etiology, guiding further diagnostic steps.

Choice D rationale

Covering the inflamed area and immediately notifying the healthcare provider without further assessment limits the nurse's contribution to data collection. While notification is ultimately necessary, the nurse should first gather more specific information about the node's characteristics and associated symptoms to provide a comprehensive report.

A. Document the client's history that is directly related to current admission diagnoses. B. Enter subjective data in the note section of the client's electronic medical record. C. Document the assessment findings on the computer at the nursing station. D. Enter the information in the electronic medical record at the client's bedside.

Correct Answer is D

Explanation

Choice A rationale

Documenting only admission-related history limits a comprehensive health assessment, potentially missing crucial co-morbidities or past medical events influencing the client's current condition and overall health. A holistic approach captures a broader spectrum of physiological and psychosocial data, which is essential for developing an individualized and safe care plan.

Choice B rationale

While subjective data is a vital component of the health history, entering it solely in a "note section" might lack structured organization, potentially making it less accessible or easily retrievable for other healthcare team members. Standardized electronic medical record fields ensure consistency and data integrity, promoting interprofessional communication and continuity of care.

Choice C rationale

Documenting at the nursing station, away from the client, introduces a temporal and spatial disconnect, increasing the risk of inaccuracies or omissions. Immediate documentation at the point of care minimizes recall bias and allows for real-time clarification or additional questioning, enhancing data reliability and the completeness of the health record.

Choice D rationale

Documenting at the client's bedside facilitates immediate and accurate entry of information, ensuring data integrity and minimizing transcription errors. This approach allows for real-time clarification of details with the client, promotes client engagement in their care, and ensures that the health record is a true reflection of the assessment findings. This also enhances workflow efficiency for the nurse.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When assessing a client’s abdomen, the nurse uses auscultation to assess for which possible finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is D

Explanation

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

A nurse is caring for a 58-year-old male client in an outpatient clinic. Select the 3 possible conditions that could have the clinical manifestations of clubbed nails for this client.

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. Which action should the nurse take in response to this finding?

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

A nurse is caring for a 40-year-old female client in an outpatient clinic. Which of the following primary skin lesions contain fluid?