A Nurse is preparing to perform an Abdominal examination of a patient. The best position to place the client is
Supine with head raised slightly and knees slightly flexed
Rationale: The Position relaxes the abdominal muscles- a totally supine position makes the abdominal muscles to be taut
A Nurse is assessing a clients muscle strength. The nurse asks the patient to hold his hands up and supinated as if holding a tray. Nurse then tells the patient to close eyes and clients left hand turns and moves downward slightly. Nurse interprets this as
A Nurse is preparing to measure the apical pulse of a client. The nurse places the diaphragm of the stethoscope on which cardiac site?
A Nurse is assessing a patient with history of cardiac problems- where should the nurse place the stethoscope to hear S1 the loudest?
A nurse is performing a musculoskeletal assessment on a client and finds that the client is right handed. The nurse would document which one of the following as abnormal findings?
Presence of Fasciculations:
Rationale- These are fine muscle twitches which are normally not present. Hypertrophy on a client's dominant side is considered normal at 1cm- muscle strength is graded from 0-5 with 0 being paralysis and 5 being normal. Symmetrical muscle movement is a normal finding.
A Nurse is performing an abdominal assessment on a client. The nurse determines which of the following findings should be reported to the physician?
Pulsations between the umbilicus and pubis
Rationale: Presence of pulsation in that area indicates presence of aortic aneurysm- should be reported to physician
What is the proper sequence for the abdominal exam
Inspect, Auscultate, percuss and palpate
A Nurse is getting ready to palpate a client's spleen. Which position would the nurse use to facilitate palpation?
Right Side Lying
When measuring abdominal girth in a client with ascites, the nurse would place the client in which position?
After performing an initial abdominal assessment on a client with a diagnosis of a cholelithiasis, the nurse documents that the bowels sounds are normal. Which of the following sounds would be considered as norma?
Relatively high pitched clicks or gurgles auscultated on all four quadrants
A Nurse performing an abdominal assessment on a patient inspects the skin of the abdomen- the nurse performs what technique next?
Listens to bowel sounds in all four quadrants
Rationale: Inspect, Auscultate, Percuss and Palpate
A Nurse assesses the client for the presence of homan's sign- which one indicates that this sign is positive?
Pain with dorsiflexion of the foot
Rationale: Homan's sign has to do with pain in the calf area (alternative heart)
When palpating a client's liver during an abdominal assessment, the nurse palpates which quadrant?
Right Upper Quadrant
The nurse finds ascites during assessment of the abdomen. The nurse would conclude that this is most likely associated with which of the following conditions?
When percussing the liver, the nurse would expect to document which of the following findings?
The Knee joint is the articulation of which of the following joints?
Femur, Patella and Tibia
When performing an assessment of the client presenting with a musculoskeletal problem, which action should the nurse take first?
Inspect the area of pain or inflammation
Heberdens and Bourchard's nodes are hard and non tender and are associated with
When testing for muscle strength, the examiner should:
A) observe muscles for the degree of contraction when the individual lifts a heavy object.
B) apply an opposing force when the individual puts a joint in flexion or extension.
C) measure the degree of force that it takes to overcome joint flexion or extension.
D) estimate the degree of flexion and extension in each joint.
B) apply an opposing force when the individual puts a joint in flexion or extension
When assessing for the presence of a herniated nucleus pulposus, the examiner would:
A) raise each of the patient's legs straight while keeping the knee extended.
B) ask the patient to bend over and touch the floor while keeping the legs straight.
C) instruct the patient to do a knee bend.
D) abduct and adduct the patient's legs while keeping the knee extended
A) raise each of the patient's legs straight while keeping the knee extended.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. The shift position is known as:
Loss of bone density
The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultating precedes percussion and palpation of the abdomen?
It prevents distortion of bowel sounds that might occur after percussion and palpation."
Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites
Tympany that changes location with client position
Explanation: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float, so dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany that changes location with client position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.
A nurse auscultates for bowels sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after one minute. What is an appropriate action by the nurse?
Listen for a total of five (5) minutes
Explanation: Bowel sounds normally occur every 5 to 15 seconds. In a client with nausea and vomiting, bowel sounds may be hypoactive. The nurse should listen for a total of 5 minutes to confirm the absence of bowel sounds. Assessing the client for dehydration is necessary but not in relation to the finding of bowel sounds. Palpation should be done after completing auscultation of the abdomen.
A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?
Explanation: The gallbladder is located in the right upper quadrant of the abdomen. When it is inflamed (cholecystitis), performing the Murphy's sign will cause the client to hold the breath (inspiratory arrest). The Obturator & Psoas tests are to determine if the appendix is inflamed. Rovsing's sign test for rebound tenderness which may indicate peritoneal irritation.
When palpating a patient's liver, the nurse feels a firm edge. What would this indicate to the nurse
Explanation: Abnormal liver findings include hepatomegaly and the firm edge of cirrhosis. A firm edge does not indicate liver failure or calcification. Splenomegaly is a distractor for this question
A nurse receives an order to measure the abdominal girth daily on a client admitted with ascites. How should the nurse best implement this order?
Measure at the same time each day, ideally in the morning after voiding
Explanation: The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand. If the client cannot stand, the supine position is acceptable. The head of bed should be flat unless the client has difficulty breathing.
A nurse is preparing discharge instructions for a patient with raynauds disease. The nurse plans to tell the patient to