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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
Correct Answer is D
Explanation
Choice A reason: Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.
Choice C reason: Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.
Choice D reason: Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.
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