A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Deep palpation

Light palpation

Auscultation

Inspection

Answer and Explanation

The Correct Answer is D,C,B,A

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale:

• Seizures: The client’s significantly elevated T3 (230 ng/dL), T4 (3.4 ng/dL), and TSI (150%) levels, along with symptoms such as anxiety, heat intolerance, insomnia, and irritability, suggest hyperthyroidism and risk for thyroid storm. This hypermetabolic state can lead to neurological complications including seizures due to increased cerebral excitability.

• Pneumonia: The client has no respiratory distress, maintains a clear airway, has normal respiratory rate and oxygen saturation, and shows no pulmonary abnormalities. There are no signs to suggest a risk for infection or hypoventilation.

• Paralytic ileus: There are no gastrointestinal symptoms such as abdominal distension, absent bowel sounds, or nausea. The client has normal GI function with a good appetite and soft brown stools, ruling out risk of ileus.

• thyroid storm: The clinical picture unplanned weight loss, exophthalmos, goiter, hyperreflexia (suggested by irritability), and insomnia aligns with Graves’ disease and severe thyrotoxicosis. Surgery can precipitate a thyroid storm if thyroid hormone levels are not well controlled beforehand.

• hypoparathyroidism: While this is a known risk after thyroidectomy due to parathyroid injury, the client has not yet had surgery at the time of the lab results and symptoms. No signs of hypocalcemia (e.g., tingling, cramps) are present either.

• laryngeal nerve damage: This is an intraoperative complication, generally presenting as hoarseness or voice changes. There are no findings suggesting vocal cord involvement, and it would not lead to seizures.

A. Occupational therapist B. Social worker C. Primary care provider D. Physical therapist

Correct Answer is B

Explanation

Rationale:

A. Occupational therapist: An occupational therapist helps clients regain skills for daily living and can assess driving ability, but they are not typically responsible for arranging transportation or addressing confidence-related psychosocial issues. A referral may follow but is not the first step here.

B. Social worker: A social worker assists clients with coping and resource coordination, including transportation services, community support, and addressing emotional or confidence barriers. This makes them the most appropriate referral when a client is unsure about attending follow-up care.

C. Primary care provider: While the PCP oversees general medical care and referrals, they are not responsible for coordinating transportation. The nurse can directly initiate a more appropriate referral rather than relying on the PCP for this non-medical concern.

D. Physical therapist: A physical therapist focuses on improving physical function, mobility, and strength. They do not handle transportation issues or confidence concerns related to attending appointments, making them less relevant in this context.

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A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Exhibits Complete the following sentence by using the lists of options. The client is most at risk for dropdown due to dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is reinforcing discharge teaching with a client who states, "I don't feel confident driving to my follow-up appointments." The nurse should obtain a referral for which of the following members of the health care team?

Correct Answer is B

Explanation

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