When assessing a patient's abdomen, the nurse notes frequent pulsations in the epigastric region. What action should the nurse take?
1. document the findings as hyperactive bowel sounds
2. review the patient's medical records for signs and symptoms of cirrhosis, which may indicate ascites
3. note the time when the patient last voided
4. notify the physician about the findings
Correct Answer: 4
Patients having an aortic aneurysm present with increased pulsations. This should be reported. Bowel sounds are audible, not visible. Bladder distention is not manifested as pulsations. Ascites is the collection of fluid.
You might also like to view...
The long-term care facility nurse should make rounds and monitor residents for safety every:
a. 2 hours. b. 4 hours. c. 6 hours. d. shift.
Which of the following is not a purpose of a research literature review for a practicing nurse?
A) To identify nursing interventions that have potential for use in evidenced-based practice. B) To identify a suitable research design C) To acquire knowledge about a relevant clinical topic D) To facilitate the development of research-based protocols
The client is 90 minutes postoperative after shoulder surgery and the Hemovac drain contains 400 ml of serosanguinous fluid since surgery. Which should the nurse do first?
1. Collaborate with the surgeon. 2. Monitor the Hemovac drainage. 3. Irrigate drain with sterile fluid. 4. Attach a larger Hemovac drain.
A patient in his mid-30s has a new diagnosis of schizophrenia and is taking chlorpromazine (Thorazine). Three days after beginning the chlorpromazine, he has jerky movements of his head and arms and he is concerned
The nurse assesses these symptoms as: A) Extrapyramidal side effects B) Dyspepsia C) Torticollis D) Dystonia