Nokea
During an abdominal examination, the nurse palpates for liver enlargement. Which technique is most appropriate?
- A. Percussion to identify liver dullness.
- B. Palpation with deep pressure on the right upper quadrant.
- C. Auscultation for liver bruits.
- D. Inspection for visible pulsations.
Correct Answer: B
Rationale: The correct answer is B: Palpation with deep pressure on the right upper quadrant. This technique is appropriate because the liver is located in the right upper quadrant of the abdomen, and palpation with deep pressure allows the nurse to feel for any enlargement or abnormalities. Percussion (Choice A) is used to identify organ borders, not necessarily to assess for enlargement. Auscultation for liver bruits (Choice C) is not typically done during a routine abdominal examination for liver enlargement. Inspection for visible pulsations (Choice D) is more indicative of an abdominal aortic aneurysm, not liver enlargement.
You may also like to solve these questions
The physician order reads 'Lopressor (metoprolol) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.' The patient's blood pressure is 92/66. The nurse does not give the medication and
- A. Does not tell the patient what the blood pressure is.
- B. Documents only what the blood pressure was.
- C. Documents that the medication was not given owing to low blood pressure.
- D. Does not need to inform the health care provider that the medication was held.
Correct Answer: C
Rationale: Holding metoprolol for BP 92/66 (<100 systolic) requires documentation of reason for accountability. Not telling is optional. BP alone lacks context. Not informing risks oversight. Choice C is correct, per nursing documentation standards.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
- A. The woman could be at increased risk for infection and lesions because of her chronic disease.
- B. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding.
- C. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors.
- D. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.
Correct Answer: A
Rationale: The correct answer is A. The woman's history of diabetes and peripheral vascular disease puts her at increased risk for infection and lesions when trying to remove the corn with scissors. Diabetes can impair wound healing and increase the risk of infection. Peripheral vascular disease can lead to poor circulation, further complicating wound healing. Choices B, C, and D are incorrect because they do not address the specific risks associated with the woman's chronic conditions. Choice B is incorrect as diabetes often causes poor circulation, not increased circulation. Choice C is incorrect as age and visual impairment are not the primary reasons for discouraging the use of scissors. Choice D is incorrect as it focuses on range of motion rather than the specific risks related to diabetes and peripheral vascular disease.
Mrs. Patton, a 48-year-old woman, comes to your office with a complaint of a breast mass. Without any other information, what is the risk of this mass being cancerous?
- A. About 10%
- B. About 20%
- C. About 30%
- D. About 40%
Correct Answer: A
Rationale: The correct answer is A: About 10%. The risk of a breast mass being cancerous in a 48-year-old woman without any other information is approximately 10%. This estimate is based on epidemiological data and risk assessment tools that consider age, family history, and other risk factors. It is important to note that the risk could vary based on individual factors, but in general, the likelihood of a breast mass being cancerous is lower in younger women. Choices B, C, and D are incorrect as they overestimate the risk without considering the specific patient's characteristics.
Mark each of the following statements as therapeutic or nontherapeutic. c. "Dr. Daniels knows what he is talking about. Just follow his recommendations."
- A. Therapeutic
- B. Nontherapeutic
Correct Answer: B
Rationale: The correct answer is B: Nontherapeutic. This statement is nontherapeutic because it implies a lack of autonomy and empowerment for the individual seeking help. It suggests blindly following advice without considering personal preferences or values. This can hinder the therapeutic process by diminishing the client's ability to actively participate in decision-making and problem-solving. Therapeutic communication focuses on collaboration, empowerment, and respect for the client's autonomy. Choices A, C, and D are left blank as they do not provide a suitable rationale for the given question.
During auscultation, the nurse hears an unfamiliar sound. The best action is to:
- A. Ignore it if the patient is asymptomatic.
- B. Ask another nurse to double-check the finding.
- C. Document the sound and continue the assessment.
- D. Reposition the patient and listen again.
Correct Answer: B
Rationale: The correct answer is B because asking another nurse to double-check the finding is crucial for validation and ensuring accuracy in assessment. This step helps in confirming the unfamiliar sound and ruling out any potential errors or misinterpretations. It promotes patient safety and effective communication among healthcare providers.
Ignoring the sound (Choice A) can lead to overlooking a significant finding that may impact the patient's condition. Documenting and continuing the assessment (Choice C) without validation may result in incomplete information and potential misdiagnosis. Repositioning the patient and listening again (Choice D) may not address the need for confirmation from another healthcare provider.