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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View Related questions
Correct Answer is A
Explanation
A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.
B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.
C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.
D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.
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.