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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.
B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.
C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.
D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.
Correct Answer is B
Explanation
A. Determine the client's most recent hemoglobin level: While low hemoglobin can be associated with conditions that cause clubbing, it's not the initial step. Documenting the finding is more important first.
B. Document the presence of nail bed clubbing: An angle of 200 degrees between the nail and nail bed is a classic sign of clubbing, which can be associated with various underlying conditions.
C. Administer a PRN prescription for oxygen: This is not indicated unless the client has respiratory problems, and clubbing itself doesn't necessitate oxygen.
D. Consult with a podiatrist: Consulting a podiatrist might be necessary for nail care in some situations, but it's not the most urgent action for nail bed clubbing. Documenting the finding and investigating the underlying cause is the priority.
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