When assessing a client's abdomen, particularly for "stomach pain," the nurse should:
Inspect
Percuss
Palpate
Auscultate
The Correct Answer is D
Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.
Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.
Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.
Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.
Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.
Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.
Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.
Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.
Correct Answer is C
Explanation
The correct answer is: c. Positioning the client’s arm above heart level.
Choice A: Wrapping the cuff too loosely around the client’s arm
Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.
Choice B: Measuring blood pressure right after the client’s mealtime
Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.
Choice C: Positioning the client’s arm above heart level
Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.
Choice D: Deflating the cuff too slowly
Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.
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