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

Assist the client to a sitting position.

Percuss the region before auscultating.

Reduce all environmental noise.

Palpate the region before auscultating.

Answer and Explanation

The Correct Answer is C

Choice a reason:
Assisting the client to a sitting position is not the best action to ensure that bowel sounds can be heard. For abdominal auscultation, the patient should be lying down in a supine position to relax the abdominal muscles, which facilitates the hearing of bowel sounds.

Choice b reason:
Percussion of the abdomen before auscultation is not recommended as the best initial action. Percussion can stimulate bowel motility, which may alter the natural bowel sounds that the nurse is attempting to assess.

Choice c reason:
Reducing all environmental noise is the best action to ensure that bowel sounds can be heard clearly. Environmental noise can mask the subtle sounds of bowel motility, and minimizing distractions allows for a more accurate assessment of bowel activity.

Choice d reason:
Palpating the region before auscultating is not the best action because palpation can also stimulate bowel motility and potentially alter the bowel sounds. Auscultation should be performed before palpation during the abdominal examination to avoid this issue.

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Correct Answer is C

Explanation

Choice a reason:
The left temporal bone would be the expected site of lateralization for sound in a Weber test if the patient had conductive hearing loss in the left ear. However, with unilateral sensorineural hearing loss, the sound typically lateralizes to the opposite ear, which is the ear with better hearing.
Choice b reason:
Lateralization to both ears equally during the Weber test would suggest either normal hearing or symmetrical hearing loss. In the case of unilateral sensorineural hearing loss, the sound is not perceived as equal in both ears because the affected ear does not hear as well as the unaffected ear.
Choice c reason:
In a patient with unilateral sensorineural hearing loss in the left ear, the Weber test will lateralize to the right ear, which is the ear with normal hearing. This occurs because the inner ear on the affected side is not able to transmit the sound as effectively as the unaffected side, making the sound seem louder in the ear with better hearing.
Choice d reason:
Lateralization to the left ear in the Weber test would indicate conductive hearing loss in the left ear, not sensorineural hearing loss. In sensorineural hearing loss, the sound vibrates to the ear with better cochlear function, which would be the right ear in this case.

A. Educational Prevention B. Tertiary Prevention C. Secondary Prevention D. Primary Prevention

Correct Answer is B

Explanation

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

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

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Naxlex Comprehensive Predictor Exams

A patient is diagnosed with left ear unilateral sensorineural hearing loss. During the performance of the Weber test, the nurse expects lateralization of the sound/vibration to the:

Correct Answer is C

Explanation

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Correct Answer is B

Explanation

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