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?

Hyperactive bowel sounds.

A minor variation.

Possible renal artery stenosis.

Normal borborygmus sounds.

Answer and Explanation

The Correct Answer is C

A) Hyperactive bowel sounds:
Hyperactive bowel sounds are typically characterized by loud, high-pitched gurgles heard throughout the abdomen. They are often associated with increased intestinal motility, such as in gastroenteritis or diarrhea, rather than a low-pitched blowing sound in the upper midline area.

B) A minor variation:
A minor variation may refer to a benign finding or a slight deviation from the norm. However, a low-pitched blowing sound in the upper midline area would not typically be considered a minor variation and may warrant further investigation.

C) Possible renal artery stenosis:
A low-pitched blowing sound in the upper midline area could indicate a renal artery bruit, which is a sign of renal artery stenosis. Renal artery stenosis is a narrowing of the renal artery, often due to atherosclerosis, which can lead to decreased blood flow to the kidneys. A renal artery bruit may be auscultated over the renal arteries and is indicative of turbulent blood flow through the narrowed artery.

D) Normal borborygmus sounds:
Borborygmi are normal bowel sounds characterized by gurgling, rumbling, or growling noises produced by the movement of gas and fluid in the intestines. However, a low-pitched blowing sound in the upper midline area would not typically be described as normal borborygmi. Borborygmi are usually heard at a higher frequency and throughout the abdomen.

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Correct Answer is A

Explanation

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.

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

Correct Answer is C

Explanation

A) Ask the client to complete a common proverb or saying:
While completing a common proverb or saying can provide some insight into speech patterns, it may not offer a comprehensive assessment of the client's speech abilities. Additionally, the client's familiarity with specific proverbs or sayings could influence their performance.

B) Have the client repeat a phrase containing alliteration:
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.

C) Note the client's responses during the initial interview:
This approach allows the nurse to observe the client's spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. It provides a comprehensive assessment of speech abilities in various contexts.

D) Listen while the client reads items listed on the menu:
While listening to the client read items on a menu can assess reading ability and pronunciation, it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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