While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

Malignancy

Aneurysm

Hernia

Peritonitis

Answer and Explanation

The Correct Answer is D

A. Malignancy can cause abdominal pain, but it does not typically present with acute sharp pain and involuntary guarding.
B. Aneurysms, particularly abdominal aortic aneurysms, may present with a pulsatile mass and deep, dull pain rather than sharp pain and guarding.
C. Hernias can cause pain, but they typically present with a bulging mass that increases with straining, not sharp pain with reflex guarding.
D. Peritonitis is correct because it causes severe abdominal pain, involuntary guarding, and rebound tenderness due to inflammation of the peritoneum. Reflex guarding is a protective mechanism indicating peritoneal irritation.

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Correct Answer is D

Explanation

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

A. Place the diaphragm against the client's clothing and angle biannuals toward nose. B. Ensure that the ear pieces are loose and comfortable in ears. C. Ask the client to hold their breath during auscultation. D. Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces.

Correct Answer is D

Explanation

A. Placing the diaphragm against clothing can interfere with sound transmission. The stethoscope should be placed directly on the skin.
B. Earpieces should fit snugly in the ears to optimize sound conduction, rather than being loose.
C. Asking the client to hold their breath is not a standard technique for improving heart sound auscultation; it is more useful for breath sounds or murmurs.
D. "Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces" is correct because background noise can interfere with auscultation, and a proper fit enhances sound transmission.

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While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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