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. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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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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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