The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Notify the healthcare provider of the rebound tenderness.

Obtain a prescription to catheterize the client's bladder.

Offer to administer a laxative prescribed for PRN use.

Instruct the client in distraction and relaxation techniques.

Answer and Explanation

The Correct Answer is A

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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Correct Answer is A

Explanation

When unable to palpate peripheral pulses, particularly the pedal pulses, using a Doppler ultrasonic stethoscope is an appropriate action to further assess circulation. The Doppler device uses sound waves to detect and amplify blood flow, allowing the nurse to locate pulses that may be difficult to palpate by traditional means. This assessment technique can provide valuable information about vascular status and potential circulation issues in the extremities.

B. Notify the healthcare provider:
Notifying the healthcare provider is not the initial action for the inability to palpate pedal pulses. The nurse should first attempt to assess the pulses using alternative methods, such as a Doppler device, before escalating the concern to the provider.

C. Apply warm blankets to both feet:
Applying warm blankets may be appropriate for clients with cold extremities due to peripheral vasoconstriction, but it does not directly address the issue of being unable to palpate pulses. Additionally, warmth alone may not improve circulation if there is an underlying vascular problem causing the absence of pulses.

D. Palpate pulse points with legs dependent:
Palpating pulse points with the legs dependent may facilitate blood flow to the lower extremities, potentially making pulses easier to palpate. However, if pulses are not palpable in the supine or seated position, it is unlikely that changing positions will significantly improve their detectability. Using a Doppler device would be a more appropriate next step in this situation.

A. Paresthesia. B. Rebound reaction to the needle points. C. Normal sensory finding. D. Marginal decline in sensory function.

Correct Answer is C

Explanation

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

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The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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