The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

Percuss the region before auscultating.

Palpate the region before auscultating.

Assist the client to a sitting position.

Answer and Explanation

The Correct Answer is A

A. Reduce all environmental noise: Minimizing environmental noise ensures that bowel sounds can be clearly heard during auscultation.

B. Percuss the region before auscultating: Percussion is not necessary before auscultation for detecting bowel sounds; auscultation should be done first.

C. Palpate the region before auscultating: Palpation can alter bowel sounds or cause false findings, so it is best to auscultate first.

D. Assist the client to a sitting position: The client’s position is less critical than reducing background noise; the client can be in various positions as long as the area is accessible.

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Correct Answer is B

Explanation

A. Ears: Evaluation of the ears is primarily concerned with hearing and balance, which involve cranial nerves such as VIII (Vestibulocochlear), not IX, X, and XII.

B. Mouth and throat: Cranial nerves IX (Glossopharyngeal), X (Vagus), and XII (Hypoglossal) are assessed through the examination of the mouth and throat. CN IX and X are evaluated by checking the gag reflex and the ability to swallow, while CN XII is assessed by examining tongue movements.

C. Head and face: The assessment of the head and face generally involves cranial nerves V (Trigeminal) and VII (Facial), which control facial sensation and movement, rather than IX, X, and XII.

D. Mental status examination: While mental status is crucial for overall health assessment, it does not specifically target cranial nerves IX, X, and XII.

A. Planning B. Diagnosis C. Evaluation D. Assessment

Correct Answer is D

Explanation

A. Planning: Planning involves setting goals and interventions based on data collected, but data collection itself is not part of this phase.

B. Diagnosis: Diagnosis involves analyzing collected data to identify health issues, but data collection is a separate process that occurs before this phase.

C. Evaluation: Evaluation assesses the effectiveness of interventions and progress towards goals, but data collection is performed earlier in the process.

D. Assessment: Data collection is a fundamental part of the assessment phase in the nursing process, where information is gathered to identify patient needs and conditions.

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The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a head-to-toe assessment, during which part would the nurse evaluate cranial nerve (CN) IX, X, and XII?

Correct Answer is B

Explanation

Data collection occurs where in the nursing process?

Correct Answer is D

Explanation

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