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 D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

A. Screen client for alcohol or controlled drug abuse. B. Evaluate client for side effects of routine medications. C. Instruct client to demonstrate activities of daily living. D. Focus questions to evaluate long term memory.

Correct Answer is C

Explanation

A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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