The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider?

Intermittent pain on deep inspiration.

An audible abdominal bruit.

A bulge over umbilicus when coughing.

Hypoactive bowel sounds in all quadrants.

Answer and Explanation

The Correct Answer is B

A.   Intermittent pain on deep inspiration could suggest pleuritic pain, which is related to the lungs or pleura rather than the abdomen. While this might be significant, it is less directly related to the client’s deep abdominal pain radiating to the back. This finding may be less urgent compared to other potential signs of serious abdominal pathology.

B.   An abdominal bruit is a sound heard over the abdomen due to turbulent blood flow, often associated with vascular abnormalities like aneurysms or significant arterial stenosis. An audible abdominal bruit, especially if associated with deep abdominal pain, could indicate a serious vascular condition such as an abdominal aortic aneurysm (AAA).
C.   A bulge over the umbilicus when coughing could indicate an umbilical hernia. While a hernia can be problematic and may require treatment, it is generally less urgent compared to findings that might suggest more acute or severe conditions like vascular issues.
D.   Hypoactive bowel sounds can indicate decreased gastrointestinal activity, which might be related to various conditions such as ileus or bowel obstruction. While this finding is significant and warrants attention, it is often less immediately critical compared to signs of serious vascular issues or acute abdominal pathology.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is C

Explanation

A. This question assesses a client's recent memory, not their judgment.
B. This question assesses a client's knowledge and understanding of animals, not their judgment.
C. This question evaluates a client's judgment by assessing their ability to make sound decisions based on hypothetical situations. It requires the client to consider potential consequences and make a logical inference.
D. This question assesses a client's financial knowledge and decision-making skills, but it doesn't directly evaluate their judgment in a hypothetical situation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Correct Answer is B

Explanation

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is C

Explanation

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?