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 B

Explanation

A. Emphasizing four important points is helpful, but it may be more effective to limit the number of points to ensure the client can focus on and remember key concepts.

B. Short teaching sessions are recommended for clients with low literacy levels because they are easier to understand and retain. Breaking down information into smaller, manageable segments can help prevent overwhelming the client.

C. Referring to the client in the third person may create distance and is not conducive to fostering a supportive, clear, and engaging learning environment.

D. Using passive voice can make the information less clear and harder for the client to understand. Active voice is generally more direct and effective in communication.

A. Checks the instrument gauge to ensure the reading starts at zero B. Places the client's arm above the level of the client's heart C. Wraps the blood pressure cuff snugly around the client's arm D. Centers the cuff bladder over the client's brachial artery

Correct Answer is B

Explanation

A. Checking the instrument gauge to ensure it starts at zero is important for accurate readings.

B. Placing the arm above the level of the heart can result in a falsely low blood pressure reading. The arm should be at the level of the heart for an accurate measurement.

C. Wrapping the cuff snugly around the arm ensures a proper fit, which is necessary for accurate readings.

D. The bladder of the cuff should be centered over the brachial artery to obtain the most accurate reading.

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