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:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

A. The immunization schedule recommended for the client's age. B. The need for regular mammogram screening to identify breast cancer lesions. C. The need for consistent use of seat belts when in a motor vehicle. D. The impact of annual vision examinations on personal health and safety.

Correct Answer is B

Explanation

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What eye function is the nurse preparing to assess when the client is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?

Correct Answer is C

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Correct Answer is B

Explanation

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