A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?

Document shiny, taut skin as an expected finding.

Perform palpation after auscultation.

Listen for 1 min before documenting absent bowel sounds.

Perform auscultation immediately after the client has consumed a meal.

Answer and Explanation

The Correct Answer is B

A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.

B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.

C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.

D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.

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Correct Answer is B

Explanation

A. "Picture yourself in one of your favorite places." This statement is related to visualization, which is a different technique, not specifically meditation.

B. "Choose a word to help focus your attention." Mantra meditation involves repeating a word or phrase to enhance focus and promote relaxation.

C. "Quickly inhale deeply and hold your breath for 30 seconds." Holding the breath for 30 seconds can increase anxiety rather than reduce it. Meditation encourages slow, deep breathing, not breath-holding.

D. "Plan for 1 hour of meditation for each session." Meditation can be beneficial even if done for a few minutes. For beginners, shorter sessions (e.g., 5–10 minutes) are recommended.

A. Provide the client with a referral to a support group. B. Encourage the client to view the body of their partner. C. Reinforce the need for the client to build new relationships. D. Encourage the client to share their thoughts and feelings.

Correct Answer is D

Explanation

A. Provide the client with a referral to a support group. Not the first priority; occurs later in the grieving process.

B. Encourage the client to view the body of their partner. Only appropriate if the client wants to do so.

C. Reinforce the need for the client to build new relationships. Insensitive and premature during initial grief.

D. Encourage the client to share their thoughts and feelings. Therapeutic communication is the first step in grief support, allowing the client to process emotions.

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A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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