A client in the emergency room is being admitted with severe right lower quadrant abdominal pain. The client states the pain is an 8 on the scale of 0-10 with sharp intermittent pain that has not been relieved by any intervention at this point. What will the nurse ask the client to do while palpating the abdomen?

Have the client lay on their left side.

Ask the client to exhale and hold their breath.

Encourage the client to raise their head off the pillow.

Assist the client in flexing their knees.

Answer and Explanation

The Correct Answer is D

A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.

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Correct Answer is B

Explanation

A. Asking what makes the pain better helps determine relief measures but does not specifically address the pattern of occurrence.
B. Asking how long these episodes have been occurring helps identify the pattern of the pain, including its frequency and duration, which is important for diagnosing chronic or recurrent conditions such as migraines or hypertension-related headaches.
C. Asking about other symptoms helps assess associated conditions but does not directly focus on the pattern of the pain.
D. Asking when the pain began helps determine onset but does not provide insight into its recurrence or fluctuation over time.

A. Secreting bile B. Absorbing electrolytes C. Secreting digestive enzymes D. Absorbing large amounts of water

Correct Answer is D

Explanation

A. The colon does not secrete bile; bile is produced by the liver and stored in the gallbladder.
B. The colon does absorb electrolytes, but its primary function is water absorption, which helps form solid stool.
C. The colon does not secrete digestive enzymes; enzyme secretion occurs primarily in the stomach and small intestine.
D. The colon's primary function is absorbing large amounts of water, which helps maintain fluid balance and form feces. Disruptions, such as in colon cancer, can lead to diarrhea or constipation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

Correct Answer is B

Explanation

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Correct Answer is D

Explanation

A nurse has completed the client's initial assessment and is preparing to identify abnormal data and the client's strengths. Which of the following is required to successfully complete this phase of the nursing process?

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

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?

A client complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

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?