The nurse is providing care to a client who is experiencing back pain. Which of the following in the client's history is a known risk factor for disc herniation?
Short stature
Anorexia
39 years of age
Female gender
The Correct Answer is C
A) Short stature: While body height can play a role in overall musculoskeletal health, short stature is not specifically identified as a risk factor for disc herniation. Other physical characteristics have a more direct impact on spinal issues.
B) Anorexia: Although nutritional status is important for general health, anorexia is not a recognized risk factor for disc herniation. The condition is more related to physical stressors and age rather than dietary habits alone.
C) 39 years of age: Age is a significant risk factor for disc herniation. Most cases occur in adults aged 30 to 50, as degenerative changes in the spine increase vulnerability to herniation. At 39, the client falls within this high-risk age range.
D) Female gender: While certain musculoskeletal conditions may vary by gender, disc herniation does not have a strong gender predisposition. Both men and women are equally affected, making this option less relevant as a specific risk factor.
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Correct Answer is D
Explanation
A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.
B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.
C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.
D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.
Correct Answer is B
Explanation
A) To establish a rapport with the client and family: While building rapport is an important aspect of the health assessment process, it is not the primary purpose. Establishing a trusting relationship can enhance communication and the quality of care, but the overarching goal of the assessment extends beyond interpersonal dynamics.
B) To establish a database against which subsequent assessments can be measured: This is the primary purpose of a health assessment. By collecting comprehensive baseline data regarding a client's health status, the nurse creates a reference point for future evaluations. This allows for the monitoring of changes in the patient's condition over time, facilitating timely interventions when necessary.
C) To gather information for specialists to whom the client may be referred: Although gathering relevant information for potential referrals is beneficial, it is not the main purpose of the health assessment. The assessment primarily serves to inform the current healthcare team about the patient's status rather than focusing solely on future consultations.
D) To qualify the degree of pain the client may be experiencing: Assessing pain is an important component of a comprehensive health assessment, but it is just one aspect among many. The overall purpose of the health assessment encompasses a broader evaluation of physical, emotional, and social factors affecting the client's health.