Which method is best for the nurse to use in determining early development of ascites?

Inspection of the abdomen for enlargement,

Palpation of an abdominal fluid wave.

Bimanual palpation for liver enlargement.

Successive measurements of abdominal girth.

Answer and Explanation

The Correct Answer is B

A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.

B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.

C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.

D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.

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Correct Answer is A

Explanation

A. Blue tinge in the nail beds: This finding is indicative of cyanosis. When oxygen levels in the blood are low, the skin and mucous membranes may appear bluish due to inadequate oxygenation. The nail beds are a common area to observe this bluish discoloration.

B. Ashen grey tone to lips: While this can be concerning, it is not a classic sign of cyanosis. Ashen grey lips may be associated with other conditions, such as shock or poor perfusion, but they do not specifically indicate cyanosis.

C. Ashy yellow appearance of skin: This finding is not related to cyanosis. An ashy yellow appearance may be seen in conditions like liver disease or jaundice, but it does not reflect oxygenation status.

D. Reddish purple colored palms: Again, this is not a sign of cyanosis. Reddish or purple palms may be seen in various conditions, but they do not specifically point to inadequate oxygen levels.

A. Demonstrates startle reflex. B. Has doubled birth weight. C. Turns head to locate sound. D. Plays "peek a boo."

Correct Answer is A

Explanation

A. Demonstrates startle reflex: The startle reflex (Moro reflex) typically disappears around 3-4 months of age. If a 6-month-old still demonstrates this reflex, it may indicate a developmental delay or neurological issue, requiring further evaluation.

B. Has doubled birth weight: Doubling of birth weight by 6 months is a normal developmental milestone. This response does not require further evaluation as it indicates appropriate growth.

C. Turns head to locate sound: Turning the head to locate sounds is expected at this age and demonstrates normal auditory and neurological development. This response does not require further evaluation.

D. Plays "peek a boo": Playing "peek a boo" is a typical social interaction for a 6-month-old and indicates normal social and cognitive development. This response does not require further evaluation.

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Which method is best for the nurse to use in determining early development of ascites?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a darkly pigmented child for cyanosis. Which finding indicates cyanosis?

Correct Answer is A

Explanation

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

Correct Answer is A

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Which method is best for the nurse to use in determining early development of ascites?

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

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While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

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