A nurse is completing a client abdominal assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

Round and Taut

White Striae

Symmetrical, Rounded shape

Soft and Non-Tender

Answer and Explanation

The Correct Answer is B

A. Round and Taut:

A round and taut abdomen may be normal, depending on the individual's body habitus and muscle tone. It might indicate normal abdominal distension associated with gas or a meal.

B. White Striae (Stretch Marks)

White striae, commonly known as stretch marks, on the abdomen may warrant further investigation. While they are often benign and associated with conditions like weight gain or pregnancy, they can sometimes be indicative of underlying issues such as Cushing's syndrome or other factors. Further inquiry or investigation into the client's medical history may be needed to understand the cause of the white striae.

C. Symmetrical, Rounded Shape:

A symmetrical and rounded abdominal shape is generally considered a normal finding. It suggests that the abdominal muscles are intact and that there is no obvious asymmetry or abnormal protrusion.

D. Soft and Non-Tender:

A soft and non-tender abdomen is a normal finding. It suggests that the abdominal

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Correct Answer is D

Explanation

A. He has an electrical burn, which caused coagulation of some tissues:

This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.

B. He is doing well, although he might be in the hospital for some time:

While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.

C. He does not appear to have much damage and should be fine soon:

This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.

D. He has an electrical burn. He is stable, and we will update you with any changes:

This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.

A. Auscultating lung sounds B. Obtaining the client’s temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the client’s respirations E. Asking the client about a family history of any illness or disease

Correct Answer is ["A","B","D"]

Explanation

A. Auscultating lung sounds:

Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.

B. Obtaining the client’s temperature:

Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.

C. Assessing the strength of peripheral pulses:

Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.

D. Obtaining information about the client’s respirations:

Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.

E. Asking the client about a family history of any illness or disease:

Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.

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A nurse is completing a client abdominal assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

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