The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse:
a. observes for skin pigmentation and discolorations.
b. looks for pulsations originating from the vena cava.
c. has the patient take a deep breath.
d. watches for signs of pain and distention.
C
The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses. Abdominal distention, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.
You might also like to view...
The nurse implements the concepts of the activity theory of aging when instructing the older cli-ent with osteoarthritis to:
a. continue her daily walking routine. b. curtail further increases in physical activi-ty. c. document preferred end-of-life interven-tions. d. avoid exposing herself to crowds.
A client is using an ophthalmic beta-blocking agent for the treatment of glaucoma. Which instruction does the nurse give to the client to prevent orthostatic hypotension?
a. "Change positions quickly after adminis-tering the drops." b. "Take your pulse at least four times daily." c. "Apply pressure to the inside corner of your eye when administering the drops." d. "Lay down for 10 minutes after adminis-tering the drops."
A patient inquires about the use of herbal therapy. Which statement by the nurse is most accurate?
A) "All herbs are equal in purity, so purchase the cheapest brand." B) "Herbs can have side effects and can interact with prescription medications." C) "Be sure to pay attention to the packaging's therapeutic and prevention information." D) "It is best if you select a licensed herbalist as a practitioner."
You are ready to give your first injection to a client. You are worried about drawing the insulin up correctly. Your instructor asks you a question. You do not answer, so the instructor speaks louder to repeat the question
You look up, apologize, and state, "I didn't hear what you said!" In thinking about this, you recognize that you had which of the following levels of anxiety? a. mild b. moderate c. severe d. panic