The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?
Auscultation.
Percussion.
Light palpation.
Deep palpation.
The Correct Answer is A
Choice A rationale: After visual inspection, the next step typically involves auscultation, which allows the nurse to listen for bowel sounds and gather information about
gastrointestinal function.
Choice B rationale: Percussion involves tapping the abdomen to assess density or abnormal masses but usually follows auscultation.
Choice C rationale: Palpation, both light and deep, follows percussion in the sequence of an abdominal examination.
Choice D rationale: Similar to light palpation, deep palpation follows auscultation and percussion in the sequence of an abdominal examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.
Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.
Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.
Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.
Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.
Correct Answer is D
Explanation
Choice A rationale: This is a sign of worsening diabetes insipidus.
Choice B rationale: This shows signs of overhydration, as urine output is high and specific gravity is high.
Choice C rationale: This is a sign of worsening diabetes insipidus.
Choice D rationale: Vasopressin is a hormone that helps the kidneys retain water and concentrate urine. Diabetes insipidus is a condition where the body does not produce enough vasopressin or does not respond to it, resulting in excessive urination and diluted urine. The goal of vasopressin therapy is to reduce urine output and increase urine concentration, which indicates that the kidneys are functioning properly and the body is hydrated.
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