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As a part of a routine health assessment, the nurse assesses the kidneys
as part of the abdominal assessment. Which assessment finding should
the nurse conclude is normal when palpating the client's right kidney? -
CORRECT-ANSWER-A round smooth mass that slides between the
fingers.
A client reports lower abdominal pain and a feeling of pressure in the
bladder. Which assessment finding indicates acute urinary retention? -
CORRECT-ANSWER-Dull sound percussed over bladder.
*Clients with acute urinary retention may present with lower abdominal
pain and bladder distension. Percussion (tapping on the body wall) is
performed to detect differences in pitch. A dull sound produced when
percussing a distended urinary bladder is an indication of urinary
retention.
The nurse examines the skin of an older adult client. Which skin
variation is considered a normal finding for a client in this age group? -
,CORRECT-ANSWER-Lentigines.
*Lentigines or commonly referred to as liver spots are irregularly shaped
dark spots on the skin caused by aging and extensive sun exposure. This
skin variation is a normal finding in an older adult client.
During the interview portio of the health assessment, a nurse notes the
person's posture, physical appearance, and ability to converse. How
should the nurse document these findings? -
CORRECTANSWERObjective.
The nurse is assessing a client who reports having shoulder pain. Which
sign is the best indicator of a rotator cuff tear? -
CORRECTANSWERInability to slowly lower the arm when abducted.
During cardiac auscultation, the nurse hears a split in the second heart
sound when listening at the second left intercostal space of a male client.
To assess this sound more fully, what action should the nurse
implement? - CORRECT-ANSWER-Listen to the sound while
observing the client's respirations.
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