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A client's bladder is found to be distended. At which location would the nurse begin palpating?

A.

At the symphysis pubis.

B.

In the left lower quadrant.

C.

At the umbilicus.

D.

In the right lower quadrant.

Answer and Explanation

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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View Related questions

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.

Correct Answer is D

Explanation

A. A client who has pneumonia: Pneumonia typically requires droplet precautions, not airborne.

B. A client who has shigella: Shigella is transmitted through the fecal-oral route, so contact precautions would be appropriate.

C. A client who has strep throat: Streptococcal infections are spread by droplets, so droplet precautions are indicated, not airborne.

D. A client who has tuberculosis: Tuberculosis (TB) is spread via airborne droplets, so airborne precautions are necessary to prevent transmission.

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