Which of the following is an unexpected finding that should be documented and reported to the provider?
Abdominal distention.
Silver striae.
Borborygmus.
Abdominal symmetry.
The Correct Answer is A
Choice A reason: Abdominal distention is an unexpected finding, potentially indicating serious issues like bowel obstruction, ascites, or organ enlargement, requiring urgent reporting. Unlike normal findings like symmetry, distention demands investigation. Prompt documentation ensures timely diagnosis and intervention, critical for preventing complications in patients with abdominal abnormalities.
Choice B reason: Silver striae are expected from skin stretching (e.g., pregnancy or weight gain), not typically concerning unless new or severe. Distention is more urgent. Assuming striae require reporting risks diverting focus from serious findings, potentially delaying evaluation of critical abdominal conditions needing immediate medical attention.
Choice C reason: Borborygmus (bowel sounds) is a normal finding, indicating active digestion, unless absent or hyperactive. Distention is abnormal and urgent. Assuming borborygmus requires reporting risks misprioritizing normal findings, neglecting serious issues like distention, critical for timely diagnosis and management of abdominal pathology.
Choice D reason: Abdominal symmetry is expected in healthy assessments, unlike distention, which signals pathology. Assuming symmetry is unexpected risks overlooking abnormal findings, diverting focus from urgent issues like obstruction or ascites. Reporting distention ensures prompt evaluation, critical for addressing underlying causes and preventing complications in patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The epidermis is the most superficial skin layer, providing a protective barrier against pathogens and UV radiation. Composed of stratified squamous epithelium, it’s critical for skin integrity. Accurate identification guides wound care and assessments, ensuring proper management of superficial injuries or conditions like dermatitis in clinical practice.
Choice B reason: Adipose tissue is deep, within the subcutaneous layer, not superficial. The epidermis is the outermost layer. Misidentifying adipose risks misunderstanding skin anatomy, leading to errors in wound staging or treatment, potentially compromising care for superficial skin conditions requiring targeted interventions like topical therapies.
Choice C reason: The subcutaneous layer lies beneath the dermis, not superficially. The epidermis is the outermost layer. Assuming subcutaneous is superficial misguides skin assessments, risking incorrect wound care or misdiagnosis of skin conditions, critical for accurate treatment and prevention of complications in integumentary health.
Choice D reason: The dermis lies below the epidermis, containing blood vessels and nerves, not the most superficial layer. Misidentifying dermis risks errors in assessing skin injuries or conditions, potentially leading to inappropriate treatments. Recognizing the epidermis ensures proper care for superficial issues like burns or abrasions in clinical settings.
Correct Answer is A
Explanation
Choice A reason: A friction rub is a scratching or squeaking sound from inflamed pleural surfaces, persisting throughout the respiratory cycle and unaffected by coughing, as pleural inflammation (e.g., pleurisy) causes consistent friction. Accurate recognition ensures proper reporting, guiding diagnosis and treatment of underlying conditions like pneumonia or pulmonary embolism in respiratory assessments.
Choice B reason: Assuming false is incorrect, as friction rubs indeed persist through the respiratory cycle without clearing by coughing, unlike rhonchi. Misidentifying this risks misdiagnosis, potentially overlooking pleural inflammation needing anti-inflammatory or antibiotic therapy, delaying treatment and increasing complications in patients with respiratory conditions causing friction rubs.
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