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

Bilateral bowel sounds in lower quadrants

Symmetrical convex sphere shape

Ecchymosis

Concave umbilicus

Answer and Explanation

The Correct Answer is C

A. Bilateral bowel sounds in the lower quadrants are normal and do not require further investigation unless they are abnormal in frequency or tone.

B. A symmetrical convex sphere shape of the abdomen can be a normal finding, especially in a well-nourished individual.

C. Ecchymosis (bruising) may be a sign of trauma, bleeding disorders, or other underlying health conditions that require further investigation.

D. A concave umbilicus may be normal or could indicate a past surgical history or conditions like malnutrition, but it doesn't inherently require investigation unless associated with other symptoms.

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Correct Answer is D

Explanation

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

A. WBC count B. BUN C. Potassium D. RBC count

Correct Answer is A

Explanation

A. An elevated white blood cell (WBC) count is a common indicator of infection. WBCs increase in response to infection as part of the body's immune response.

B. BUN (blood urea nitrogen) may be elevated in dehydration or renal dysfunction, not necessarily due to infection.

C. Potassium levels are typically related to electrolyte imbalances, not directly indicative of infection.

D. RBC count is related to anemia or blood volume, not infection.

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

Nursing Test Bank

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