A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

Choice A rationale:

Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.

Choice B rationale:

Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.

Choice C rationale:

Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.

Choice D rationale:

Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.

Choice A rationale:

"Tell me about your coping strategies and support system." This is an appropriate statement during the assessment of a client with panic disorder. Understanding the client's coping mechanisms and support system can help the nurse tailor the care plan to the client's specific needs and strengths.

Choice B rationale:

"How often do you experience panic attacks and what triggers them?" While this question may be relevant, it focuses primarily on the frequency and triggers of panic attacks. While this information is important, it doesn't address coping strategies or support systems, which are equally important aspects of the assessment.

Choice C rationale:

"What medications are you currently taking for your panic disorder?" This question is essential for medication management but does not directly address coping strategies or support systems, which are more pertinent to the assessment in this context.

Choice D rationale:

"Have you ever had any laboratory tests done for your panic disorder?" This question is not relevant to the assessment of panic disorder. Panic disorder is primarily diagnosed based on clinical criteria and does not require specific laboratory tests.