Author Question: The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action ... (Read 77 times)

strangeaffliction · **on:** Jul 23, 2018

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse?

1. Percuss for flatness over the liver.
2. Palpate for bladder fullness.
3. Use the p.r.n. order to medicate the client with an antacid.
4. Inspect the sacral area for edema.

Question 2

The client who is unconscious is developing foot drop. What nursing action is indicated?

1. Place high-topped shoes on the client while in bed.
2. Keep the linens on the end of the bed turned back to expose the feet.
3. Use only the prone and Sims positions for client positioning.
4. Use a device to elevate the linens off the feet.

mk6555 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: Flatness is the normal percussion sound over the liver.
Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort.
Rationale 3: The nurse should not medicate the client until assessment is complete.
Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain.

Answer to Question 2

Correct Answer: 1
Rationale 1: High-topped shoes will place the client's feet in the anatomical position of dorsal flexion.
Rationale 2: Turning the linens back will keep the weight of the linens off of the feet but will not prevent foot drop.
Rationale 3: The prone and Sims positions are implicated in the development of foot drop.
Rationale 4: A device to elevate the linens off of the feet will not prevent foot drop.