During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

1 minute in the center of the abdomen.

10 minutes in each quadrant.

1 minute in each quadrant.

5 minutes in each quadrant.

None

Answer and Explanation

The Correct Answer is D

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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Correct Answer is ["A"]

Explanation

A. Abdominal distention can occur due to gas accumulation from undigested lactose.
B. Visible peristalsis is not typically a specific clinical finding associated with lactose intolerance.
C. Hypoactive bowel sounds are not commonly associated with lactose intolerance.
D. Occasional diarrhea is a common symptom due to the inability to digest lactose properly.
E. Flatus or excessive gas production is a common symptom due to the fermentation of undigested lactose by intestinal bacteria.

A. Tell the adolescent everything will be fine and there's nothing to worry about. B. Complete an assessment and notify the emergency department physician immediately. C. Perform a focused assessment and document. D. Document pain assessment as normal.

Correct Answer is B

Explanation

A. Reassurance is important, but it should be given after a thorough assessment and appropriate actions have been taken.
B. Completing an assessment and promptly informing the physician allows for timely intervention in case of testicular torsion or other serious conditions causing severe testicular pain.
C. Performing a focused assessment is crucial but shouldn't delay immediate notification of the physician in such a critical situation.
D. Documenting pain assessment is important but not the priority when a client presents with severe, acute pain in a sensitive area like the testicles.

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During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

Correct Answer is ["A"]

Explanation

An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following should be the priority action by the nurse?

Correct Answer is B

Explanation

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During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

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