The nurse completes percussion of the abdomen on an older adult client.
Which finding is considered normal for this client?
Tenderness.
Musical and drumlike.
Absent sounds.
Pain.
The Correct Answer is B
Choice A rationale:
Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.
Choice B rationale:
Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.
Choice C rationale:
Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.
Choice D rationale:
Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","H"]
Explanation
Choice A rationale:
A Speech Therapist is crucial in this case. The patient presented with garbled speech, which indicates a possible speech impairment. A speech therapist can evaluate the patient’s speech and language skills and provide therapy to improve any deficits, which can significantly enhance the patient’s quality of life.
Choice B rationale:
A Case Manager is essential in coordinating the patient’s care. They ensure that the patient’s healthcare needs are met and that the patient is receiving appropriate treatments. They also coordinate with various healthcare professionals and may assist with insurance issues or discharge planning.
Choice C rationale:
A Physical Therapist can help the patient regain physical strength and mobility that might have been affected by the stroke. They can provide exercises and treatments to improve balance, coordination, and muscle strength, which can help the patient regain independence in their daily activities.
Choice D rationale:
A Pharmacy Technician is not typically involved in direct patient care or recovery. Their role is more focused on assisting pharmacists with dispensing medication and other administrative tasks in a pharmacy setting.
Choice E rationale:
The Chief Nursing Officer (CNO) is a high-level executive role that oversees nursing staff across an entire healthcare organization. While they play a crucial role in ensuring quality nursing care, they would not be directly involved in individual patient recovery.
Choice F rationale:
A Respiratory Therapist could be helpful if the patient had respiratory issues or complications related to the stroke, but given the information provided, it does not appear that respiratory therapy is needed in this case.
Choice G rationale:
A Medical Assistant typically performs administrative and clinical tasks in healthcare settings but does not specialize in rehabilitation or recovery care for stroke patients.
Choice H rationale:
An Occupational Therapist is vital for stroke recovery. They can help the patient regain skills needed for daily living activities that might have been affected by the stroke, such as eating, dressing, and bathing. They can also provide strategies to compensate for any lasting deficits from the stroke. In summary, for a comprehensive recovery plan for this patient who has had a stroke, an interdisciplinary team involving a Speech Therapist (A), Case Manager (B), Physical Therapist ©, and Occupational Therapist (H) would be most beneficial.
Correct Answer is ["B"]
Explanation
The correct answer is Choice B.
Choice A rationale: While notifying the charge nurse about the client’s condition is important, it is not the most critical action. The charge nurse’s role would be to coordinate care and ensure appropriate resources are available, but the immediate safety and well-being of the client and others in the facility is the priority. Therefore, this choice is not the most important action for the nurse to take.
Choice B rationale: Instituting droplet precautions, placing the client in a private room, and keeping the door closed is the most important action. COVID-19 is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Therefore, it is crucial to implement droplet precautions to prevent the spread of the virus. This includes wearing a mask, eye protection, and a gown and gloves when caring for the client. The client should also be placed in a private room with the door closed to further prevent the spread of the virus.
Choice C rationale: While it is important for the client to inform others that they may have been potentially exposed, this is not the most critical action. The priority is to prevent the spread of the virus within the healthcare facility. Once the client is appropriately isolated and precautions are in place, the client can be educated and assisted with notifying others about potential exposure.
Choice D rationale: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a standard procedure when collecting specimens for testing. However, this action does not address the immediate need to prevent the spread of the virus within the healthcare facility. Therefore, this choice is not the most important action for the nurse to take.
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