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. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

A. To ensure valid conclusions are made when analyzing data. B. To reassess previously detected problems to note any changes. C. To determine the need for crisis intervention. D. To identify strengths and limitations in lifestyle and health status.

Correct Answer is B

Explanation

A. Ensuring valid conclusions when analyzing data is part of the initial assessment rather than the purpose of a partial assessment.
B. Reassessing previously detected problems to note any changes is correct because partial assessments are conducted to monitor the client's progress and detect any new or worsening symptoms.
C. Crisis intervention is not the primary purpose of a partial assessment unless a crisis is evident.
D. Identifying strengths and limitations in lifestyle and health status is a component of the initial comprehensive assessment rather than the partial assessment.

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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

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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