When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

Hernia.

Aneurysm.

Tympany.

Appendicitis.

Answer and Explanation

The Correct Answer is B

A.   A hernia may present as a bulge in the abdomen, but it is not typically pulsating. It is usually a soft, non-pulsatile mass.
B.   A pulsating centrally localized abdominal distention is characteristic of an abdominal aneurysm, which occurs when the wall of the aorta weakens and bulges. The pulsation is often palpable and can be dangerous if ruptured.
C.   Tympany refers to a sound produced during percussion, which is typically heard over air-filled structures like the stomach, but it doesn’t cause pulsating distention.
D.   Appendicitis typically presents with localized pain in the lower right abdomen and is not associated with pulsating abdominal distention.

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Correct Answer is C

Explanation

A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.

A. "Count backwards by 7, starting with 100." B. "What does, "The early bird catches the worm," mean?" C. "Has anyone come to visit you today?" D. "In what year were you born?"

Correct Answer is B

Explanation

A. This tests the client’s ability to perform mathematical tasks but does not specifically assess abstract
thinking. It is more of a concrete cognitive task.

B. This question assesses abstract thinking because it requires the client to interpret a proverb, which involves understanding symbolic meaning beyond the literal words.
C. This question is assessing more of the client’s orientation and memory rather than abstract thinking. It does not test higher-level cognitive abilities.
D. This is an orientation question, assessing the client’s ability to recall personal facts, but it does not
assess abstract reasoning skills.

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When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

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Naxlex Comprehensive Predictor Exams

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