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
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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Related Questions
Correct Answer is D
Explanation
A. Develop a plan of care for the client:
Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.
B. Provide a schedule of visiting hours to the client’s family:
While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.
C. Teach the client about his diagnosis:
Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.
D. Document the client’s code status
When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.
Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.
Correct Answer is A
Explanation
A. Validate the finding:
Validating the finding involves rechecking the patient's temperature using a different thermometer or method to confirm the accuracy of the initial measurement. This step is crucial to rule out any potential errors or issues with the measurement.
B. Document the finding:
Once the finding has been validated and confirmed, the nurse should document the elevated temperature accurately in the patient's medical record. Documentation is essential for communication among the healthcare team and for tracking changes in the patient's condition over time.
C. Inform the surgeon:
If the elevated temperature is confirmed and the patient is scheduled for surgery, it is important to inform the surgeon promptly. The surgeon needs to be aware of any changes in the patient's health status that may impact the decision to proceed with the scheduled surgery.
D. Inform the charge nurse:
Informing the charge nurse may be appropriate, especially if there are specific protocols or procedures in place within the healthcare facility for addressing unexpected changes in a patient's condition. The charge nurse can provide guidance and coordinate appropriate actions.
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