A client is being seen in the emergency department for abdominal pain. Based on the client's history, the nurse believes the client may have an abdominal aortic aneurysm. Which method of physical assessment should the nurse employ in this situation?
a. Deep palpation of all four quadrants of the abdomen
b. Auscultation of the abdomen to listen for bruits
c. Inspection of the abdomen to assess for signs of skin gathering
d. Percussion over the upper third of the abdomen
b. Auscultation of the abdomen to listen for bruits
rationale: "Auscultation of the abdomen to listen for bruits" is correct. An abdominal aortic aneurysm is an area of the descending aorta in which the wall of the vessel is enlarged and stretches outward. The condition is a medical emergency if it ruptures. The nurse may assess for an aneurysm by auscultating with a stethoscope. The nurse should hear a bruit of turbulent blood flow through the vessel.
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Which activity should a patient avoid 24 to 48 hours before a scheduled physical assessment to prevent affecting the results of the Pap smear and other cultures?
a. ingesting alcohol or smoking b. taking a tub bath, swimming, or using a hot tub c. taking birth control pills or other hormones d. using vaginal sprays, douching, or having coitus
A 62-year-old male patient has had chronic obstructive pulmonary disease (COPD) for many years but has been unable to quit smoking. When approached by the nurse, he states that he would be "better off dead."
He states that he has always supported his family, and now the doctor says he can no longer work because of his condition and oxygen dependency. His wife will now have to go to work, and he is sure that she will not make enough money to pay the bills. In preparing the patient for discharge, the nurse should a. Develop a plan of care for the family. b. Contact psychiatric services. c. Assure the patient that things will work out. d. Focus the plan of care on maximizing patient function.
When Ashae, a CNA, attempts to give an enema to a patient, she finds that he cannot insert the tip of the enema bottle. It seems to push against something hard. What should Ashae do?
A. Have the patient breathe deeply, then try to insert the tip further. B. Inform her supervising nurse of the problem. C. Insert the tip deeper, up to 5 inches. D. Press on the patient's abdomen, to release the blockage.
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?
A) Administer a bolus of IV fluids. B) Arrange for the insertion of a peripherally inserted central catheter. C) Administer nebulized bronchodilators every 2 hours until the test. D) Withhold food and fluids for several hours before the test.