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. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.

B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.

C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.

D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.

A. "I think you will regret it if you don't have this surgery." B. "It's too late to cancel your cataract surgery." C. "This surgery is painless, so you shouldn't worry." D. "Share with me more about the thoughts that are concerning you.”

Correct Answer is D

Explanation

A. "I think you will regret it if you don't have this surgery." – This is non-therapeutic and pressures the client rather than encouraging discussion.

B. "It's too late to cancel your cataract surgery." – This is false information; clients have the right to refuse treatment at any time.

C. "This surgery is painless, so you shouldn't worry." – This minimizes the client’s concerns and dismisses their feelings.

D. "Share with me more about the thoughts that are concerning you." – This therapeutic response encourages the client to express their concerns, allowing the nurse to address them appropriately.

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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

A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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