A client complains of constipation and gas pains. The nurse prepares to complete a physical examination of the client's abdomen. What is the best order in which the nurse will complete this assessment of the abdomen on the client?
A) Inspection, palpation, auscultation
B) Inspection, auscultation, palpation
C) Auscultation, inspection, palpation
D) Palpation, auscultation, inspection
B
Feedback:
Palpation is done only after inspection and auscultation, to prevent pockets of gas from moving in the intestines and being mistaken for normal bowel sounds.
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The nurse is caring for a patient who has been belligerent and is in four-point "leather" restraints. The patient is verbally abusive and still tries to kick and punch staff even though he is restrained. The nurse should:
a. ignore the patient's needs until he "calms down." b. strike the patient if necessary to protect herself/himself. c. continue to attempt to meet the patient's needs. d. threaten the patient with retaliation if he doesn't stop.
A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered. The nurse identifies that this patient is experiencing the second stage of Kübler-Ross' stages of dying
What is the second stage? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression
The nurse is reviewing the care of an 89-year-old client who has a stage I decubiti on the coccyx and right heel. The nurse provides instruction to the nurse aide assigned to care for the client
What would the nurse include in the instruction to the nurse aide? A) keep the bed elevated 45? or higher B) turn the client on the side to remove sheets and clothing C) use dry dressings to the heels D) use soap to cleanse the skin
A patient being prepared for a heart transplant is concerned that the transplanted organ will not be accepted in his body. What should the nurse consider when formulating a response to this concern?
1. Heart transplants are very successful because of immunosuppressant medication. 2. Today it is more common to do heart-lung transplants. 3. Hearts were the first organs to be transplanted so the technique has been perfected. 4. There are no guarantees since transplants are more successful between twins.