While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

"Client's gastrointestinal health is within normal limits."

"Gastrointestinal problems are not present at this time."

"Client denies gastrointestinal signs and symptoms."

"Client denies recent constipation, diarrhea, bowel incontinence or abdominal pain."

Answer and Explanation

The Correct Answer is D

D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.

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Correct Answer is C

Explanation

A. Pressing in the right upper quadrant is not appropriate for a referred rebound tenderness test, which is used to assess peritoneal irritation, commonly from appendicitis.
B. Pressing in the left upper quadrant is not useful in diagnosing appendicitis or conditions that cause referred pain to the right lower quadrant.
C. Pressing in the left lower quadrant is correct when performing Rovsing’s sign, a test for referred rebound tenderness. If the client experiences pain in the right lower quadrant when the left lower quadrant is pressed, it suggests peritoneal irritation, often due to appendicitis.
D. Pressing in the right lower quadrant would directly elicit tenderness in appendicitis but does not test for referred rebound tenderness.

A. In the left lower quadrant. B. At the symphysis pubis. C. In the right upper quadrant. D. Above the umbilicus.

Correct Answer is B

Explanation

A. The left lower quadrant contains portions of the small and large intestines but is not the starting point for palpating the bladder.
B. The nurse should begin palpating at the symphysis pubis because the bladder is located in the lower abdomen. When distended, it rises above the pubic symphysis and can extend toward the umbilicus.
C. The right upper quadrant contains the liver and gallbladder but is not relevant to bladder assessment.
D. A significantly distended bladder may extend above the umbilicus, but the nurse should begin palpation at the symphysis pubis and move upward to assess for distention.

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While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Correct Answer is C

Explanation

A nurse is performing a comprehensive abdomen assessment including inspection, auscultation, and palpation. Upon palpation, the client's bladder is found to be distended. What location would the nurse begin palpating for the distended bladder?

Correct Answer is B

Explanation

What is the primary purpose of a nursing health assessment?

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