When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?
Flat
Protuberant
Rounded
Scaphoid
The Correct Answer is D
A. Flat: A flat abdomen is level with no visible protrusions or concavities.
B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.
C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.
D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.
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Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
A. Postural hypotension: Postural hypotension (a drop-in blood pressure when moving to a standing position) is a common sign of extracellular fluid volume deficit due to decreased circulating blood volume.
B. Dependent edema: This occurs with fluid volume excess, not deficit, due to fluid accumulation in tissues.
C. Bradycardia: Fluid volume deficit often leads to tachycardia as the body compensates for low blood volume, rather than a slow heart rate.
D. Distended neck veins: Distended neck veins suggest fluid overload, not a fluid deficit.