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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Gloves are used to protect against direct contact with bodily fluids, not specifically for droplet transmission.
B. A gown is generally used for contact precautions or to protect from body fluid exposure, not droplet transmission.
C. Goggles are used to protect the eyes from splashes or droplets, but they are not typically required for droplet precautions unless there is a risk of eye exposure.
D. A mask is required for droplet precautions, as droplet transmission can occur when a person coughs or sneezes. Wearing a mask helps prevent the spread of respiratory droplets.
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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