While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

The gallbladder is normal.

Deeper palpation technique is needed.

The client is too obese.

Palpating in the wrong abdominal quadrant.

Answer and Explanation

The Correct Answer is A

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Correct Answer is D

Explanation

A. Triceps skin fold and mid-arm circumference. These measurements can provide some indication of nutritional status, but they may not be as reliable in older adults due to changes in body composition and skin elasticity.

B. Twenty-four-hour food recall, preferences, and allergies. While dietary information is important, it may not accurately reflect the client's current nutritional status.

C. Weight loss history and body surface area (BSA). While weight loss history is relevant, BSA is not typically used to assess nutritional status.

D. Body mass index (BMI) and serum albumin level. BMI is a commonly used indicator of nutritional status, and serum albumin level reflects protein status, which is important for assessing malnutrition.

A. Compress the tissue around the ankles. B. Observe plantar flexion and dorsiflexion. C. Palpate the volume of the pedal pulses. D. Stroke the soles and note toe movement.

Correct Answer is C

Explanation

A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.

B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.

C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.

D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.

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While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting an older adult client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is D

Explanation

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

Correct Answer is C

Explanation

The nurse auscultates a client's breath sounds as seen in the picture. Which type of normal sounds should the nurse hear over these lung fields?

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

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When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

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