During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation?
Ask about recent abdominal trauma.
Palpate the area for masses.
Document the normal finding.
Observe the midline for scarring.
The Correct Answer is C
Choice A Reason:
Ask about recent abdominal trauma: in this case, the depressed umbilicus is a normal finding, so no further action related to trauma assessment is necessary.
Choice B Reason:
Palpate the area for masses: Palpating the area for masses is a good practice during abdominal assessments. However, in the context of a depressed umbilicus, this finding is not indicative of an abnormal mass. Therefore, palpation is not specifically warranted.
Choice C Reason:
Document the normal finding: Correct! A depressed umbilicus that lies below the surface of the abdomen is considered a normal variation. Documenting this finding ensures accurate and comprehensive assessment documentation.
Choice D Reason:
Observe the midline for scarring: While observing the midline for scarring is relevant in some situations (such as assessing for surgical scars), it’s not directly related to the depressed umbilicus. Therefore, this action is not necessary based on the specific finding described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.
Correct Answer is D
Explanation
Choice A Reason:
Black tarry stools are inappropriate. Black tarry stools may indicate gastrointestinal bleeding, which is not directly related to the client's symptoms of suprapubic tenderness and pressure after urination. While it's important to consider other potential health issues, such as gastrointestinal bleeding, it may not be directly relevant to the client's current urinary symptoms.
Choice B Reason:
A cloudy discharge is inappropriate. A cloudy discharge may suggest an infection or inflammation in the urinary tract, but it is not specifically associated with the symptoms described by the client (suprapubic tenderness and pressure after urination). While urinary tract infections (UTIs) can occur in older adults, they may present with symptoms such as urinary urgency, frequency, dysuria, and hematuria, rather than suprapubic tenderness and pressure after urination.
Choice C Reason:
An overactive bladder is inappropriate. While overactive bladder can cause urinary urgency and frequency, it is less likely to present with suprapubic tenderness and pressure after urination. Overactive bladder is characterized by sudden, involuntary contractions of the bladder muscles, leading to a frequent and urgent need to urinate. It may not directly explain the client's symptoms of suprapubic tenderness and pressure after urination, which are more suggestive of urinary obstruction due to BPH.
Choice D Reason:
A weak urinary stream is appropriate. Benign prostatic hyperplasia (BPH) is a common condition in older men characterized by noncancerous enlargement of the prostate gland, which can lead to compression of the urethra and urinary symptoms. A weak urinary stream is a classic symptom of BPH due to the obstruction caused by the enlarged prostate gland, which interferes with the normal flow of urine. Therefore, the nurse should expect a weak urinary stream as an additional finding during the client interview, which is consistent with the suspected diagnosis of BPH.
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