Health assessment · practice question

A 74-year-old client on a medical-surgical unit is being evaluated for abdominal assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which assessment approach should the nurse use first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026health-assessment

Defer assessment until all medications are administered.Screen for instability, then perform a focused assessment related to the presenting concern.Begin invasive procedures before any focused assessment.Use only the chart from admission without current data.

Answer and explanation

Correct answer

B. Screen for instability, then perform a focused assessment related to the presenting concern.

Why

Assessment begins with stability screening and focused data collection before invasive or delayed actions.

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A 74-year-old client on a medical-surgical unit is being evaluated for abdominal assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which assessment approach should the nurse use first?

Correct answer

Why

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