While performing an abdominal assessment on a patient, the nurse notes an abdomen shape similar to the rounded abdomen only greater. This contour is anticipated in pregnancy and seen in adults with ascites and obesity. What term should the nurse use to document this finding?
Rounded
Scaphoid
Flat
Protuberant
The Correct Answer is D
A. Rounded describes a normal abdomen but does not convey the greater extent of fullness seen in this case.
B. Scaphoid describes a concave abdomen, which does not apply to this situation.
C. Flat indicates no significant contour changes, which does not apply here.
D. Protuberant is the correct term, as it describes an abdomen that is significantly distended and is characteristic of conditions like pregnancy, ascites, or obesity.
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Correct Answer is C
Explanation
A. The right upper quadrant is typically associated with gallbladder or liver issues, not duodenal ulcers.
B. The right lower quadrant is primarily associated with appendicitis or other conditions involving the appendix.
C. The left upper quadrant is where the duodenum is located, making it the appropriate area to assess for pain related to a duodenal ulcer.
D. The left lower quadrant is often associated with conditions affecting the sigmoid colon or left ovary but not typically with duodenal ulcers.
Correct Answer is A
Explanation
A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.
B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.
C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.
D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.