A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
Prior to percussing the abdomen
Prior to inspecting the abdomen
After checking int kidney tenderness
After palpating the abdomen
The Correct Answer is A
A. Prior to percussing the abdomen
Bowel sounds are typically auscultated before performing any other abdominal assessments. This allows the nurse to get an accurate representation of the client's bowel activity without any interference from other assessment techniques.
B. Prior to inspecting the abdomen
Inspecting the abdomen involves observing for any visible abnormalities, such as distension or lesions. Bowel sounds are auscultated first to get an initial sense of the client's gastrointestinal activity.
C. After checking for kidney tenderness
Kidney tenderness assessment is not directly related to bowel sounds. These assessments are separate and do not impact each other's sequence.
D. After palpating the abdomen
Palpating the abdomen should be done after auscultation. Palpation can stimulate bowel activity, potentially altering the natural bowel sounds. Therefore, it is essential to auscultate the abdomen before palpating it.
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Related Questions
Correct Answer is C
Explanation
A. Diabetes mellitus
Diabetes mellitus can cause easy bruising and slow wound healing, but it is not typically associated with frequent nosebleeds.
B. Hepatitis A
Hepatitis A primarily affects the liver and does not cause frequent bruising and nosebleeds.
C. Cirrhosis
Cirrhosis, which is scarring of the liver tissue due to long-term liver damage, can lead to impaired liver function. One consequence of cirrhosis is decreased production of clotting factors, which can result in easy bruising. Additionally, the enlarged spleen in cirrhosis can lead to thrombocytopenia (low platelet count), contributing to bleeding tendencies, including nosebleeds. Cirrhosis is the most likely condition given the symptoms described.
D. Cholecystitis
Cholecystitis is inflammation of the gallbladder and is not directly associated with frequent bruising and nosebleeds.
Correct Answer is D
Explanation
A. Ecchymosis of the extremities: Ecchymosis refers to the medical term for a bruise. It's characterized by a discoloration of the skin resulting from bleeding underneath, typically caused by trauma to the blood vessels. This is not directly related to cholelithiasis.
B. Tenderness in the left upper abdomen: Tenderness in the left upper abdomen might be associated with conditions such as pancreatitis or splenic issues, not directly with obstruction and inflammation of the common bile duct due to cholelithiasis.
C. Straw-colored urine: Straw-colored urine is normal and healthy. Dark-colored or cloudy urine might indicate underlying issues, but straw-colored urine is generally a sign of proper hydration.
D. Fatty stools: When the common bile duct is obstructed due to cholelithiasis, proper digestion of fats doesn't occur, leading to the passage of fatty stools. This is due to the inability to properly digest and absorb fats, leading to their presence in the stool.
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