During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

Ask about recent abdominal trauma.

Observe the midline for scarring.

Document the normal finding.

Palpate the area for masses.

Answer and Explanation

The Correct Answer is C

A) Ask about recent abdominal trauma:
While abdominal trauma could potentially cause changes in the appearance of the umbilicus, such as bruising or swelling, it is not the most likely explanation for a depressed umbilicus below the surface of the abdomen. Additionally, without further evidence or symptoms suggestive of trauma, it may not be necessary to immediately inquire about recent abdominal trauma.

B) Observe the midline for scarring:
Observing the midline for scarring may be relevant if there are signs of previous surgical procedures or other abdominal interventions. However, the presence of a depressed umbilicus below the surface of the abdomen does not necessarily indicate scarring or previous surgery.

C) Document the normal finding:
A depressed umbilicus below the surface of the abdomen is a normal anatomical variation in some individuals, particularly those with a more slender build or a deeper abdominal cavity. It does not typically indicate pathology or require further intervention.

D) Palpate the area for masses:
Palpating the area for masses may be indicated if there are other signs or symptoms suggestive of abdominal pathology, but a depressed umbilicus alone is not typically an indication for palpation. In the absence of other concerning findings, it may be unnecessary and potentially uncomfortable for the client to perform palpation based solely on the observation of a depressed umbilicus.

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Correct Answer is A

Explanation

Ecchymosis refers to the discoloration of the skin resulting from bleeding underneath, typically due to bruising. While ecchymosis can occur for various reasons, the use of oral anticoagulants increases the risk of bleeding and bruising. Therefore, the nurse should further assess the client's use of oral anticoagulants to determine if it is contributing to the observed ecchymosis.

B. Works in a day care center:
Working in a day care center may expose the client to various infectious agents, but it is not directly associated with the development of ecchymosis.

C. Recently had dental surgery:
While dental surgery can sometimes result in minor bleeding and bruising, it is less likely to cause widespread ecchymosis unless there are underlying bleeding disorders or complications.

D. Adheres to a gluten-free diet:
Adhering to a gluten-free diet is not directly related to the development of ecchymosis. However, if the client has celiac disease or another condition requiring a gluten-free diet, the nurse should explore the potential for malabsorption or nutritional deficiencies, which could indirectly contribute to bleeding tendencies.

A. Ask the client to complete a common proverb or saying. B. Have the client repeat a phrase containing alliteration. C. Note the client's responses during the initial interview. D. Listen while the client reads items listed on the menu.

Correct Answer is C

Explanation

A) Ask the client to complete a common proverb or saying:
While completing a common proverb or saying can provide some insight into speech patterns, it may not offer a comprehensive assessment of the client's speech abilities. Additionally, the client's familiarity with specific proverbs or sayings could influence their performance.

B) Have the client repeat a phrase containing alliteration:
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.

C) Note the client's responses during the initial interview:
This approach allows the nurse to observe the client's spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. It provides a comprehensive assessment of speech abilities in various contexts.

D) Listen while the client reads items listed on the menu:
While listening to the client read items on a menu can assess reading ability and pronunciation, it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

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During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Correct Answer is C

Explanation

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