A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

Gurgling bowel sounds every 10 seconds

Centrally located umbilical protrusion

Abdominal distention during breathing

Rebound tenderness with palpation

Answer and Explanation

The Correct Answer is D

Choice A reason: Gurgling bowel sounds every 10 seconds are considered normal, as normoactive bowel sounds range from 5 to 30 sounds per minute. This finding indicates regular gastrointestinal activity and is not typically a cause for concern.

Choice B reason: A centrally located umbilical protrusion can be a normal finding, especially if it has been present since birth and is not associated with any other symptoms. However, if new or associated with pain or other symptoms, it could indicate a hernia or other pathology.

Choice C reason: Abdominal distention during breathing can be a normal finding, as the abdomen may distend slightly during deep breathing due to the movement of the diaphragm. However, if the distention is pronounced or associated with other symptoms, it may warrant further investigation.

Choice D reason: Rebound tenderness with palpation is a sign of peritoneal irritation and can be an indication of conditions such as appendicitis, which is a surgical emergency. This finding should be considered a priority as it may require immediate intervention.

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Correct Answer is B

Explanation

Choice A reason: Droplet precautions are used for diseases that are transmitted through large respiratory droplets produced by coughing, sneezing, or talking. AIDS, caused by the Human Immunodeficiency Virus (HIV), is not transmitted through respiratory droplets, so droplet precautions are not necessary for a client with AIDS.

Choice B reason: Standard precautions are the primary strategy for the prevention of infection transmission and apply to all patients receiving care in hospitals, regardless of their diagnosis or presumed infection status. These precautions include hand hygiene, the use of personal protective equipment (PPE) like gloves and gowns, and safe injection practices. Since HIV/AIDS can be transmitted through blood and certain body fluids, standard precautions are essential when caring for clients with AIDS.

Choice C reason: Airborne precautions are used for diseases that are transmitted by small droplet nuclei that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance. HIV/AIDS is not transmitted through the airborne route, so airborne precautions are not indicated for clients with AIDS.

Choice D reason: Contact precautions are used for infections that are spread by direct contact with the patient or indirect contact with surfaces or patient care items. While HIV can be present in body fluids, it is not easily transmitted through casual contact. Therefore, contact precautions are not specifically required for clients with AIDS unless they have other conditions that warrant such precautions.

A. "You should limit discussing past events with the client." B. "We will respect what is important to you." C. "We will arrange all burial services." D. "Grieving should not be done in front of the client."

Correct Answer is B

Explanation

Choice A reason: The statement "You should limit discussing past events with the client" does not necessarily incorporate the client's and family's cultural beliefs. Discussing past events can be a part of reminiscence therapy, which can be beneficial for clients with terminal illnesses. It allows them to reflect on their life experiences and can provide a sense of fulfillment or closure.

Choice B reason: Saying "We will respect what is important to you" is a broad and inclusive statement that acknowledges the importance of the client's and family's cultural beliefs. It implies that the care team is willing to listen and adapt the care plan to align with the client's values, which is a fundamental aspect of culturally competent care. This approach can help ensure that the client's end-of-life care is respectful and responsive to their individual needs.

Choice C reason: Offering to "arrange all burial services" may not be appropriate as it assumes that the family requires assistance with this aspect of care without first understanding their specific cultural or religious practices. It is important to have a conversation with the client and family about their preferences and needs regarding end-of-life rituals before making any arrangements.

Choice D reason: The statement "Grieving should not be done in front of the client" may not align with the cultural beliefs of the client and family. Grieving practices vary widely among different cultures, and some may find it important to express grief openly in the presence of the dying person. It is essential to respect and accommodate the family's grieving process.

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A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

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