Abdominal Assessment and Elimination PDF

### Abdominal Assessment and Elimination 1. **A student nurse documenting progress notes should: ** Ensure accurate, concise, and timely documentation, focusing on objective data. 2. **Sunken abdomen with visible ribs is described as: ** Scaphoid abdomen. 3. **In gastroenteritis, the bowel soun...

### Abdominal Assessment and Elimination 1. **A student nurse documenting progress notes should: ** Ensure accurate, concise, and timely documentation, focusing on objective data. 2. **Sunken abdomen with visible ribs is described as: ** Scaphoid abdomen. 3. **In gastroenteritis, the bowel sounds are likely to be: ** Hyperactive bowel sounds. 4. **Alternative to catheterization for an 86-year-old incontinent male: ** Incontinence pads or external urinary collection devices like condom catheters. 5. **Most effective position for rectal suppository administration: ** Left lateral or Sims’ position. 6. **Urinary retention is defined as: ** Inability to empty the bladder completely. 7. **Ideal position for bedpan use to promote normal defecation: ** Semi-Fowler’s position or sitting up. 8. **Suspect fecal impaction when a patient who has not passed stool in 10 days experiences: ** Leakage of liquid stool, abdominal discomfort, or a distended abdomen. 9. **Ascites is defined as: ** Accumulation of fluid in the peritoneal cavity. ### Musculoskeletal and Safe Handling 10. **Palm down with elbows straight tests for: ** Pronation. 11. **Kyphosis is defined as: ** An excessive outward curvature of the thoracic spine, leading to a hunched posture. 12. **Normal ROM of the shoulder includes: ** Flexion, extension, abduction, adduction, and full rotation without pain. 13. **Care plan indicates appropriate description of patient problems when: ** There is a clearly defined nursing diagnosis supported by assessment data. 14. **Correct rule for using a mobile hoist: ** Ensure that the hoist and sling are suitable for the patient’s weight and size, and always use two caregivers. 15. **Tendency to take smaller steps with feet close together in older persons may result in * Increased risk of falls. 16. **A normal gait does not include: ** Shuffling steps or dragging feet. ### Medication Administration 17. **The seven rights of medication administration :** Right patient, right medication, right dose, right route, right time, right documentation, and right reason. 18. **Unexpected negative effect of medication is termed: ** Adverse effect. 19. **Ultimate responsibility for correct medication administration lies with: ** The nurse administering the medication. 20. **Before administering medication, always ask the patient: ** "Can you tell me your name and date of birth?" 21. **Pharmacodynamics is best described as: ** The effect of the drug on the body, including the mechanism of action. 22. **When the patient says the pill looks different, the nurse should :** Double-check the prescription and medication with the pharmacy before administering. 23. **Documenting medication given under the tongue uses the term: ** Sublingual. 24. **Flucloxacillin 250mg po QID is administered: ** By mouth, four times daily. ### Diabetes 25. **The most common risk factor for Type 2 Diabetes: ** Obesity. 26. **Symptoms of confusion, cold and clammy skin, and dizziness in a diabetic patient indicate: ** Hypoglycemia. 27. **Three common complications of diabetes mellitus include: ** Retinopathy, nephropathy, and neuropathy. 28. **HbA1c monitors glucose control over: ** Approximately 2-3 months. 29. **True statement about T1DM: ** It is an autoimmune disease where the pancreas produces little or no insulin. ### Sexual Health 30. **Genital warts education includes: ** Caused by human papillomavirus (HPV), can be prevented with vaccines, and require treatment but may recur. 31. **Additional information before proceeding to physical exam for urethral discharge includes * Sexual history, any recent risky behaviors, and the presence of other symptoms like fever. 32. **Not a bacterial sexually transmitted infection (STI): ** Genital herpes (viral). 33. **Incorrect factor about breast cancer: ** Breast cancer always presents with a lump (it can also present with skin changes, nipple discharge, etc.). ### Nutrition and Oral Assessment 34. **Folate is particularly important for: ** Pregnant women to prevent neural tube defects. 35. **Foods not permitted on a clear liquid diet: ** Cream-based soups. 36. **A BMI greater than 30 increases the risk of * Cardiovascular disease, type 2 diabetes, and hypertension. 37. **Common factor affecting nutrient absorption in older adults: ** Decreased gastrointestinal motility. 38. **For a stroke patient with dysphagia and facial weakness, assist them to eat by:** Positioning them upright, offering small bites, and using a thickened liquid if needed. 39. **Not a nose abnormality: ** Macrotia (refers to ears). ### Wound Assessment 40. **To prevent a reddened coccyx from progressing, the nurse should: ** Reposition the patient regularly and use pressure-relieving devices. 41. **Tissue surfaces of an incision that are close together are described as:** Approximated. 42. **Debridement is defined as: ** The removal of dead or damaged tissue from a wound. 43. **The hemostasis phase of wound healing is characterized by: ** Blood clotting and vessel constriction to stop bleeding. 44. **Pressure injury on the right heel with subcutaneous fat exposed is classified as:** Stage 3. 45. **Braden Scale assesses risk factors including:** Sensory perception, moisture, activity, mobility, nutrition, and friction/shear. ### Mental Health/De-escalation 46. **Appropriate approach to de-escalate Jane’s anger: ** Listen calmly, acknowledge her concerns, and offer to investigate the situation further. 47. **Delirium is characterized by: ** Acute confusion, fluctuating consciousness, and disorganized thinking. 48. **Effective question to assess orientation in mental health assessment: ** "Can you tell me the name of this place and today’s date?" ### Lymph Node Assessment 49. **To palpate the occipital lymph nodes, the nurse should place fingers: ** At the base of the skull. 50. **Symptoms commonly associated with enlarged lymph nodes include: ** Tenderness, swelling, and possible fever.