A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden, severe abdominal pain. Which of the following actions should the nurse take first?
Perform abdominal palpation by pressing gently with the finger pads.
Determine areas of resonance across the abdomen using a systematic approach.
Expose the client's abdomen to look for changes in appearance.
Use the diaphragm of a stethoscope to listen for bowel sounds.
The Correct Answer is C
Choice A reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Choice B reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice C reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D reason:
Listening for bowel sounds can provide information about the function of the gastrointestinal system. Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The client has an implanted defibrillator is the correct answer. Magnet therapy involves the use of magnets to alleviate pain and promote healing. However, it is contraindicated for individuals with implanted electronic devices, such as pacemakers or defibrillators, as the magnetic field could potentially interfere with the functioning of these devices. The safety of using magnet therapy with implanted devices has not been established, and caution is advised.
Choice B reason:
Allergic to penicillin is incorrect. Allergies to penicillin or other substances are not related to the use of magnet therapy.
Choice C reason:
The history of alcohol use disorder is incorrect. A history of alcohol use disorder does not directly contraindicate the use of magnet therapy.
Choice D reason:
The prescription for metoprolol is incorrect. Metoprolol is a common medication used to treat various conditions, including hypertension and certain heart conditions. It is not a contraindication for magnet therapy.
Correct Answer is A
Explanation
Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.
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