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
Explanation
A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.
B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.
C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.
D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.
Correct Answer is A
Explanation
A. "You must feel frustrated." This response is therapeutic and validates the nurse’s feelings, encouraging the nurse to open up about their frustration without feeling judged or defensive.
B. "Why do you feel upset about this?": Asking “why” may make the nurse defensive and feel as though they need to justify their feelings.
C. "You should be working harder.": This is unsupportive and could worsen the nurse’s frustration, possibly making them feel criticized or undervalued.
D. "I will reprimand your team members.": This response is reactive and could disrupt team dynamics without addressing the underlying issue. It does not support open communication.