During an assessment, the nurse notices that a patient's umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition?
a. Intra-abdominal bleeding
b. Constipation
c. Umbilical hernia
d. Abdominal tumor
ANS: C
The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
You might also like to view...
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."
An ICU nurse has just assisted the physician in placing a central line on a client. Over the past few days the client?s son has been verbally abusive to the nursing staff and this abuse has escalated over the past 2 days
Another nurse informs the nurse the client?s son is in the hallway wanting to see the client. Which action by the nurse would be appropriate? 1. Remove the central line tray from the room. 2. Inform the son regarding the client?s condition. 3. Ignore the son. 4. Limit the son?s visitation.
An older client being treated for pneumonia is given a sedative to sleep. A few hours afterwards, the client has a respiratory rate of 12 and cannot be aroused. What does this assessment finding indicate to the nurse?
1. The sedative was not absorbed. 2. The sedative has reached a therapeutic blood level. 3. The medication for sleep caused excessive sedation. 4. The client is experiencing complications of pneumonia.
The nurse is providing teaching to a client who has just been diagnosed with breast cancer. How would the nurse describe a malignant tumor?
Standard Text: Select all that apply. 1. Slow growing 2. Invasive 3. Lethal if left untreated 4. May be classified as a carcinoma 5. May be classified as a sarcoma