A 67-year-old male client is admitted to a health care facility with abdominal pain and suspected abdominal aneurysm. The client relates a 10-year history of high blood pressure and history of arterial insufficiency diagnosed 7 years ago. Following auscultation of the abdomen for bowel sounds, what other assessment should the nurse perform at this time?

Observe for evidence of increased abdominal girth.

Palpate the abdomen for masses, pulsations.

Auscultate for a friction rub.

Listen with the bell of the stethoscope for vascular sounds.

Answer and Explanation

The Correct Answer is D

A. Observing for increased abdominal girth is important for conditions such as ascites but is not the priority assessment for a suspected abdominal aneurysm.
B. Palpating the abdomen for masses or pulsations is contraindicated in suspected abdominal aneurysms, as it may cause rupture.
C. Auscultating for a friction rub is used for liver or spleen inflammation and is not relevant in this case.
D. Listening with the bell of the stethoscope for vascular sounds is correct because an abdominal aneurysm may produce a bruit, which can be heard over the affected artery. This assessment helps confirm the presence of turbulent blood flow, a key sign of an aneurysm.

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Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

A. Lithotomy B. Dorsal recumbent C. Sim's position D. Prone

Correct Answer is B

Explanation

A. Lithotomy position is used for gynecologic, rectal, or urologic exams and would not be comfortable for a client with low back pain.
B. Dorsal recumbent position is correct because it allows the client to lie on their back with knees bent, reducing strain on the lower back while facilitating assessment of the chest, extremities, and peripheral pulses.
C. Sim’s position is used for rectal examinations or enemas and is not ideal for assessing the chest and extremities.
D. Prone position (lying face down) would exacerbate low back pain and make it difficult to examine the chest and extremities.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is preparing to examine the chest, extremities, and peripheral pulses of a client who has low back pain. What is the best position to place this client in to assure they are comfortable for the exam?

Correct Answer is B

Explanation

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?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

A student nurse is completing a radial pulse assessment on their client and is uncertain about the assessment findings and the amplitude of the pulses. What is the priority action by the student?

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

A nursing student correctly describes a risk diagnosis by which of the following statements?

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

What is the primary purpose of a nursing health assessment?