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When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

Flat

Protuberant

Rounded

Scaphoid

Answer and Explanation

The Correct Answer is D

A. Flat: A flat abdomen is level with no visible protrusions or concavities.

B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.

C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.

D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.

B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.

C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.

D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.

E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.

A. 2 full minutes. B. 1 full minute. C. 5 full mutes. D. 1 1/2 minutes.

Correct Answer is C

Explanation

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

View Question and Answer

What subjective assessment information in this client situation is the most important and immediate concern for the nurse?

View Question and Answer

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

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Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is assessing a client who just received hearing aids. Which of the following actions should indicate to the nurse that the client understands how to use the hearing aids? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

The absence of bowel sounds is established after listening for:

Correct Answer is C

Explanation

A nurse is assessing a client who has a medical history of chronic kidney disease for fluid volume excess. Which assessment data provides the most reliable measure of fluid retention?

A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

A nurse says to their nurse manager that, "I'm the only one on my team who is working hard." Which of the following responses should the nurse manager make?