The nurse is assessing a patient's abdomen and notes that the patient has ascites. What physical examination technique should the nurse use next?

Correct Answer: A

Rationale: The correct answer is A: Percussion for shifting dullness. Ascites is the accumulation of fluid in the peritoneal cavity leading to abdominal distension. By percussing the abdomen for shifting dullness, the nurse can identify fluid waves within the abdomen, confirming the presence of ascites. This technique helps differentiate ascites from other causes of abdominal distension. Auscultation for bowel sounds (B) is not directly related to assessing ascites. Palpation for tenderness (C) may be performed after confirming ascites to assess for underlying causes. Inspection for visible distension (D) can provide initial clues, but percussion for shifting dullness is needed for a definitive diagnosis of ascites.

Correct Answer: B

Rationale: Vital signs are fundamental indicators used by healthcare professionals to assess the basic physiological functions of the body, such as temperature, pulse, respiration, and blood pressure. An indication of basic body functioning, accurately captures this concept because vital signs reflect how well the body is maintaining homeostasis and performing essential tasks like circulation and oxygenation. Signs and symptoms of a disease, is incorrect because vital signs are not exclusively tied to illness; they are monitored in healthy individuals too. A part of human composition, is vague and does not specify function, while Physiology and anatomy, refers to broader scientific fields rather than the specific measurements vital signs represent. Thus, B is the most precise and appropriate definition, aligning with clinical practice where vital signs serve as a baseline for evaluating health status.

Correct Answer: A

Rationale: produced as a byproduct of metabolic activities that generate energy for cellular functions, is correct as metabolism (e.g., in liver, muscles) generates heat via ATP production. No other choices are provided, but this aligns with physiology: cellular respiration converts nutrients into energy, releasing heat to maintain 98.6°F. Shivering or exercise boosts this, but basal metabolism is primary. The hypothalamus regulates this heat against losses (e.g., radiation). Unlike external sources, internal metabolic heat is constant, supporting homeostasis. Nursing recognizes this in fever (increased metabolism) or hypothermia (decreased). Thus, A is accurate, reflecting the bodys fundamental heat production mechanism.

Correct Answer: A

Rationale: The tympanic method measures temperature via the ear canal, requiring specific precautions. An earache contraindicates this method because pain suggests inflammation or infection, risking inaccurate readings or discomfort. Earwax can affect accuracy but isn't an absolute contraindication if minimal. An ear infection is similar to an earache but less specific here; A encompasses it. Taking the temperature in the downward ear after sleeping may skew results due to trapped heat. Choice A is correct as it prioritizes patient comfort and accuracy, reflecting clinical guidelines to avoid tympanic measurement in painful or inflamed ears, ensuring reliable vital sign assessment.

Correct Answer: C

Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation , often from external factors or exertion, not set-point shifts. A downward set-point shift isn't hyperthermia. An upward shift defines fever, not hyperthermia. Reduced mechanisms may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.