A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Percuss

Auscultate.

Palpate.

Inspect

Answer and Explanation

The Correct Answer is D

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

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Correct Answer is C

Explanation

A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.

B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.

C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.

D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.

A. "Do you take any recreational drugs?" B. "Did you have a blood transfusion recently? C. "Have you eaten any shellfish lately?" D. "Have you traveled to a third world country in the past two months?"

Correct Answer is D

Explanation

A. "Do you take any recreational drugs?"

This question is related to the risk of hepatitis transmission through the sharing of needles or other drug paraphernalia. Hepatitis B and C can be transmitted through contaminated needles used for injecting drugs.
B. "Did you have a blood transfusion recently?"

This question addresses the risk of hepatitis transmission through blood transfusions. While this used to be a significant risk, modern blood screening procedures have greatly reduced this risk. However, it's still a relevant question to understand the client's medical history.
C. "Have you eaten any shellfish lately?"

This question is related to the risk of hepatitis A transmission. Hepatitis A is often transmitted through contaminated food or water. Shellfish from contaminated waters can be a source of hepatitis A infection.
D. "Have you traveled to a third world country in the past two months?"

This question is crucial because hepatitis A is often more prevalent in developing countries and can be contracted through contaminated food, water, or poor sanitation. Travel history can help identify possible exposure sources.

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A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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