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 B

Explanation

A. Timing for testicular examination isn't as crucial as recognizing changes in the testicles. While showering might facilitate the exam, it's not the only appropriate time.
B. Noticing an enlargement or painless lump is a crucial sign that requires immediate medical attention for evaluation.
C. Performing a testicular examination once a week might not be necessary for most individuals. Monthly self-examination is often recommended.
D. Describing the testicle's normal characteristics is helpful, but recognizing changes such as lumps or enlargements is more critical for self-examination.

A. When the client sticks out the tongue it is in the midline and without tremors or deviation. B. Client follows an object with eyes without nystagmus or strabismus. C. Client demonstrates the ability to hear normal conversation. D. Client moves the head and shoulders against resistance with equal strength.

Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

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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

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

Correct Answer is B

Explanation

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

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