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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:
Splint the affected joint is inappropriate action. While splinting may help stabilize the joint and reduce movement, it may not directly address the underlying cause of the symptoms, which is9levated uric acid levels leading to gout. Additionally, splinting may further restrict range of motion and exacerbate discomfort.
Choice B Reason:
Encouraging fluid intake is appropriate action. Encouraging fluid intake, particularly water, is beneficial for individuals experiencing a gout flare-up. Adequate hydration helps to dilute uric acid in the bloodstream and promote its excretion through urine, which can help alleviate symptoms and prevent further flare-ups. Therefore, option B is the most appropriate action for the nurse to advise the client in this situation.
Choice C Reason:
Increasing intake of red meat is inappropriate action. Red meat is high in purines, which can contribute to elevated uric acid levels and increase the risk of gout flare-ups. Therefore, increasing intake of red meat would not be advisable for someone experiencing gout symptoms. In fact, dietary modifications often involve reducing intake of purine-rich foods like red meat to help manage gout.
Choice D Reason:
Measuring urine output is inappropriate action. While monitoring urine output is important for overall hydration status, it may not be the most immediate or relevant action in this situation. The priority in managing a gout flare-up is to address the underlying cause by promoting uric acid excretion through adequate hydration, rather than solely focusing on measuring urine output.

A. Assess conjunctival sacs of lower lids for pallor. B. Observe the client's urine for dark orange color. C. Examine client's sclera for icterus. D. Review recent serum bilirubin levels.

Correct Answer is C

Explanation

Choice A Reason:
Assessing conjunctival sacs of lower lids for pallor is incorrect. Pallor of the conjunctival sacs, or inner eyelids, may indicate anemia or decreased blood flow. While it can be a sign of various health conditions, it is not specific to jaundice. Jaundice is characterized by yellowing of the skin and sclerae (the white part of the eyes) due to elevated bilirubin levels in the blood, so assessing for pallor would not directly confirm jaundice.
Choice B Reason:
Observing the client's urine for dark orange color is incorrect. Dark orange urine may indicate concentrated urine or dehydration, but it is not specific to jaundice. Jaundice primarily manifests as yellowing of the skin and sclerae due to elevated bilirubin levels, rather than a change in urine color. While changes in urine color may occur in certain liver conditions, such as obstructive jaundice, it is not the most direct or reliable method to confirm jaundice.
Choice C Reason:
Examining client's sclera for icterus is correct. Icterus, or yellowing of the sclerae (the white part of the eyes), is a classic sign of jaundice. Elevated levels of bilirubin in the blood lead to the yellow discoloration of the sclerae, providing a direct visual confirmation of jaundice. Examining the sclerae for icterus is a quick and reliable method to confirm jaundice during a physical assessment.
Choice D Reason:
Reviewing recent serum bilirubin levels is incorrect. Reviewing recent serum bilirubin levels can provide objective data on bilirubin levels in the blood, which may support the diagnosis of jaundice. Elevated serum bilirubin levels are characteristic of jaundice. While this option provides valuable information, it may not be immediately available during a physical assessment and does not directly confirm jaundice visually, unlike examining the sclerae for icterus.

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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. What action should the nurse take in response to this observation?

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