A client comes to the emergency department with severe pain and tenderness in the groin area. The nurse suspects an incarcerated hernia. Which of the following assessments should the nurse prioritize?
Assessing the client's blood pressure and heart rate.
Obtaining a detailed history of the client's diet and eating habits.
Evaluating the client's range of motion and joint flexibility.
Monitoring the client's oxygen saturation and respiratory rate.
The Correct Answer is A
Choice A reason:
This statement is correct. Assessing the client's blood pressure and heart rate is a priority in a client with an incarcerated hernia as it can indicate signs of compromised blood flow to the herniated tissue and potential strangulation.
Choice B reason:
Obtaining a detailed history of the client's diet and eating habits may be important for certain conditions, but it is not a priority assessment in a client with a suspected incarcerated hernia.
Choice C reason:
Evaluating the client's range of motion and joint flexibility may be relevant for musculoskeletal assessments, but it is not a priority in a client with a suspected incarcerated hernia.
Choice D reason:
Monitoring the client's oxygen saturation and respiratory rate may be important in various conditions, but it is not a priority assessment in a client with a suspected incarcerated hernia.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
While a physical examination and medical history can provide valuable information, imaging studies are often needed to visualize and confirm the presence of a hernia accurately.
Choice B reason:
Blood tests and urinalysis are not typically used to diagnose hernias. They may be ordered to assess for other conditions or rule out other possible causes of symptoms.
Choice C reason:
This statement is correct. Imaging studies such as ultrasound, CT scan, or MRI are commonly used to visualize and confirm the presence of a hernia, assess its size, location, and determine the most appropriate treatment.
Choice D reason:
A biopsy is not necessary to diagnose a hernia. A biopsy involves the removal of tissue for examination and is usually performed to assess for cancer or other abnormal growths.
Correct Answer is B
Explanation
Choice A reason:
Incisional hernias occur at the site of a previous surgical incision and may not change with positional changes.
Choice B reason:
This statement is correct. Umbilical hernias are characterized by a bulge or lump in the abdominal area that is more noticeable when standing or exerting pressure and may disappear when lying down.
Choice C reason:
Femoral hernias are typically located in the upper thigh and may not be affected by positional changes.
Choice D reason:
Indirect inguinal hernias may present with a bulge or lump in the inguinal area, but the lump typically does not change with positional changes.
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