Exhibits

The nurse is assessing the client for bowel sounds.

Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Use a warmed bell of the stethoscope and place it lightly over the four quads

Place the stethoscope in the ears with the earpieces pointing towards the ears

Tum the suction off while auscultating

Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent

Palpate the abdomen before auscultating

Answer and Explanation

Correct Answer : A,C,D

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

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Correct Answer is C

Explanation

A. A thickened and bulging tympanic membrane typically indicates a middle ear infection, such as otitis media, not an external ear infection, and would not be expected in this case based on the symptoms described.
B. A retracted and non-mobile tympanic membrane suggests Eustachian tube dysfunction or fluid in the middle ear, which does not correlate with the external ear symptoms of itching, pain, and discharge after swimming.
C. A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as "swimmer's ear." This condition is characterized by inflammation of the external auditory canal, often following water exposure, which matches the client’s symptoms and history.
D. A translucent, pearly gray and mobile tympanic membrane is the appearance of a normal tympanic membrane, which would not be expected in a client with the described symptoms of pain, itching, and discharge associated with otitis externa.

A. Have the client repeat a phrase containing alliteration B. Note the client's responses during the initial interview C. Ask the client to complete a common proverb or saying D. Listen while the client reads items listed on the menu

Correct Answer is B

Explanation

A. Having the client repeat a phrase containing alliteration can assess articulation and phonation but does not provide a comprehensive evaluation of overall speech patterns, including fluency, coherence, and comprehension.
B. Noting the client's responses during the initial interview is an effective way to assess speech patterns in a natural, conversational context. This approach allows the nurse to evaluate the client's language use, coherence, and any speech abnormalities.
C. Asking the client to complete a common proverb or saying can assess abstract thinking and cognitive function but is not specifically aimed at evaluating speech patterns such as fluency or coherence.
D. Listening while the client reads items listed on the menu might assess reading ability and articulation but does not provide a full assessment of conversational speech patterns or the ability to express thoughts coherently.

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Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is C

Explanation

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Correct Answer is B

Explanation

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Exhibits

The nurse is assessing the client for bowel sounds.

Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.