Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?
Abdominal x-ray
Shifting dullness
Fluid wave
Ultrasound
The Correct Answer is D
A. Abdominal x-ray: While it can show gas or bowel obstructions, it is less effective for confirming fluid presence.
B. Shifting dullness: This physical exam technique can indicate fluid but is less accurate than ultrasound.
C. Fluid wave: This physical exam can help suggest the presence of fluid, but it is also less reliable than imaging studies.
D. Ultrasound: An ultrasound is the most accurate and non-invasive way to confirm the presence of fluid, such as ascites, in the abdomen. It provides detailed imaging and confirmation without invasive procedures.
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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.
Correct Answer is ["B","C","D","E"]
Explanation
A. Cleanses the ear molds with isopropyl alcohol to remove cerumen: Alcohol is not recommended for cleaning hearing aids, as it can damage the device. A mild soap and water solution or a designated cleaning tool is preferable.
B. Turns off the hearing aids when not in use: Turning off hearing aids conserves battery life, which is a proper maintenance practice.
C. Inspects the ear molds to determine the ear canal portion: Properly positioning the hearing aids ensures correct use and comfort.
D. Turns the volume all the way down before inserting the hearing aids: This prevents a sudden loud noise that could startle the client and allows them to adjust to a comfortable volume after insertion.
E. Ensures that the ears are not blocked with cerumen: Blocked cerumen can interfere with hearing aid functionality, so this is an essential step.