Author Question: The nurse is about to palpate the client's abdomen to determine the margins of the liver. The ... (Read 37 times)

yoroshambo · **on:** Jul 23, 2018

The nurse is about to palpate the client's abdomen to determine the margins of the liver. The pri-mary reason for using the bimanual palpation method is to:

1. Minimize client discomfort
2. Minimize lower hand desensitivity
3. Assist in manipulation of the organ
4. Facilitate quick assessment of the abdomen

Question 2

A client reports pain in his left ankle since twisting it yesterday. Which of the following as-sessment findings best supports the client's claims of ankle pain?

1. The client grimaces when walking to the examination room.
2. The client's left ankle is swollen with noted bruising.
3. The client reports a pain rating of 7 on a scale of 1 to 10.
4. The client's heart rate increases after walking to the examination room.

gstein359 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 2
When using bimanual palpation, relax one hand (sensing hand) and place it lightly over the cli-ent's skin. Use the other hand (active hand) to apply pressure to the sensing hand. The lower hand does not exert pressure directly and thus remains sensitive to detect organ characteristics. This technique does assist in the effective, efficient assessment of the abdomen, but its primary purpose is directed towards hand sensitivity.

Answer to Question 2

ANS: 2
A subsequent physical assessment can reveal information that refutes, confirms, or supplements the history. Think critically about the information the client provides, apply knowledge from pre-vious clinical care, and methodically conduct the examination to create a clear picture of the cli-ent's status. The objective signs of swelling and bruising best support the possible spraining of the ankle and the resulting claim of pain. The increase in heart rate is subjective but can be a re-sult of various factors, pain being only one. The remaining options reflect objective data.