Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process?
a. Light palpation
b. Deep palpation
c. Percussion
d. Auscultation
D
Auscultation precedes palpation or percussion of the abdomen because these techniques can sti-mulate peristalsis, which may alter correct assessment of the abdominal sounds. Light palpation, deep palpation, and percussion should not be completed until auscultation is completed.
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A child has been diagnosed with sickle-cell disease. The parents ask the nurse how their child got this disease. Which of the following is the best response to give the parents?
1. The mother and the father of the child have the sickle-cell trait. 2. The mother of the child has the trait, but the father doesn't. 3. The father of the child has the trait, but the mother doesn't. 4. The mother of the child has sickle-cell disease, but the father doesn't have the disease or the trait.
An older resident of a nursing home reports to the nurse that during the night someone entered her room and stood by the window watching her. She expresses fear of going to sleep. What action is most appropriate for the nurse to take initially?
a. Reassure her that there was no one in her room and that she must have been dreaming. b. Request a psychiatric consult to evaluate her for cognitive problems. c. Assess the environment in her room to see if there is anything that could be confusing her. d. Suggest to her that she request sleeping medication every night.
A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide (Lasix) through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action?
A. Verifying the physician's prescription B. Sitting and talking to the client to alleviate his concern C. Explaining to the client that the oral route will not permit the medication to exert an adequate effect D. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized
A newly diagnosed person with diabetes asks you a number of questions about a new type of insulin she is taking. You are not familiar with this. You:
a. recommend she contact the drug company to help her with her questions b. set up a referral to a Certified Diabetes Educator c. tell her all insulins work the same d. none of these