A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

After palpating the abdomen

Prior to percussing the abdomen

Prior to inspecting the abdomen

After assessing for kidney tenderness

Answer and Explanation

The Correct Answer is B

A.   After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B.   Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C.   Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D.   After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

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Correct Answer is A

Explanation

A. This statement is incorrect. While HIPAA allows for certain disclosures to family members, it is important to follow specific guidelines and obtain appropriate consent or authorization from the client when sharing their health information. There are also circumstances where a client may request that information be withheld from certain family members.
B. This statement is correct. HIPAA is a federal law that establishes privacy standards for protected health information.
C. This statement is correct. A client's address is considered personally identifiable information under HIPAA.
D. The statement appears to be cut off. However, it is important to note that HIPAA does indeed establish regulations for protecting individually identifiable health information in various forms, including verbal, electronic, and written.

A. He is hard of hearing. B. Confusion C. Pain D. Language barrier E. None F. None

Correct Answer is B

Explanation

A. He is hard of hearing:
This is unlikely. While hearing impairment could explain some difficulty in communication, it would not explain the flinching upon abdominal palpation or the wandering behavior. Hearing-impaired clients typically respond to nonverbal cues or attempt to communicate their understanding in other ways.

B. Confusion:
This is correct. The client's wandering behavior, lack of verbal response, and smiling/nodding without clear understanding are indicative of confusion, which is common in older adults experiencing delirium, dementia, or other cognitive impairments. The flinching during abdominal palpation suggests a physical issue, but the client's inability to articulate his discomfort further supports confusion as a contributing factor.

C. Pain:
While pain could explain the flinching during palpation, it does not account for the wandering behavior or the lack of meaningful verbal communication. Pain may coexist with confusion but is not the primary explanation for his overall behavior.

D. Language barrier:
A language barrier could explain difficulty in verbal communication, but it does not account for the wandering behavior or the flinching upon palpation. Additionally, the family’s ability to communicate with the healthcare team suggests this is not the most likely factor

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A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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