When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

"Refrain from eating or drinking for at least thirty minutes."

"Lie in a prone position with slightly flexed knees."

"Exhale slowly through your mouth then hold your breath."

"Empty your bladder just prior to the examination."

Answer and Explanation

The Correct Answer is D

A.   The client should refrain from eating or drinking for other procedures but not specifically for an abdominal examination unless indicated for tests like ultrasounds.
B.   A prone position is not necessary for an abdominal exam; lying on the back is preferred.
C.   The client should not hold their breath during the abdominal exam unless asked to assist with specific maneuvers.
D.   Having the bladder empty before the examination reduces discomfort and allows for better visualization of the abdominal organs.

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

Explanation

A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.

A. Ask the client if he took any pain medication at home. B. Observe for nonverbal signs to measure pain intensity. C. Use a standard pain assessment questionnaire and scale. D. Collect a urine sample and strain for granules or calculi.

Correct Answer is D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

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When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

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Naxlex Comprehensive Predictor Exams

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

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

Explanation

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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