A client's bladder is found to be distended. At which location would the nurse begin palpating?
At the symphysis pubis.
In the left lower quadrant.
At the umbilicus.
In the right lower quadrant.
The Correct Answer is A
A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.
B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.
C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.
D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.
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Correct Answer is ["A","E","F"]
Explanation
A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.
B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.
C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.
D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.
E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.
F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.
Correct Answer is ["A","C","D"]
Explanation
A. The client has legal authority to do so: The nurse’s signature confirms that the client appears to have the legal capacity to consent.
B. The client does not have a mental health condition: This is not within the nurse’s purview to assess unless explicitly stated; mental capacity, not condition, is key.
C. The client was not coerced: The nurse’s signature also indicates the consent was given voluntarily, without coercion.
D. The client signed in the nurse's presence: The nurse’s signature confirms that the nurse witnessed the client’s signature.
E. The client speaks the same language as the nurse: Consent requires understanding, which can be provided through an interpreter, so this is not necessary.