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 A
Explanation
A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.
B. The radial pulse can be assessed bilaterally without risk.
C. The brachial pulse can also be assessed bilaterally without concern.
D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.
Correct Answer is D
Explanation
A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.
B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.
C. In the heart assessment, auscultation follows inspection but may not involve percussion.
D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.