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. Wheezes B. Rhonchi C. Crackles D. Stridor

Correct Answer is A

Explanation

A. Wheezes are high-pitched continuous sounds heard during exhalation, commonly associated with asthma due to narrowed airways.

B. Rhonchi are low-pitched sounds caused by airflow obstruction in the larger airways and typically clear with coughing.

C. Crackles (or rales) are high-pitched sounds heard during inhalation and are often associated with fluid in the lungs, such as in pneumonia or heart failure.

D. Stridor is a high-pitched sound heard during inspiration and is often indicative of upper airway obstruction.

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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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