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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

A. A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting B. A 66 year old with type I diabetes that has ketones present in their urine. C. A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. D. A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL.

Correct Answer is D

Explanation

Choice A rationale: This may indicate a different condition such as gastroenteritis rather than Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS).

Choice B rationale: This is more indicative of diabetic ketoacidosis (DKA) rather than HHNS.

Choice C rationale: A 72-year-old with a history of diabetes, elevated blood glucose, and complaints of thirst and frequent urination might have uncontrolled diabetes, but the absence of severe hyperglycemia and other symptoms specific to HHNS makes this choice less likely.

Choice D rationale: This fits the criteria for HHNS. The infection, missed medication, and extremely high blood glucose levels suggest the possibility of Hyperglycemic Hyperosmolar Nonketotic Syndrome.

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The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Correct Answer is C

Explanation

Which of the following patients is most likely experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms?

Correct Answer is D

Explanation

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