A clinical instructor is reviewing the abdominal assessment with a group of students.
She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)
Hyperresonance.
Flatness.
Dullness.
Resonance.
Tympany.
Correct Answer : B,E,C
Choice A rationale
Hyperresonance is a booming sound elicited during percussion, typically heard over hyperinflated lung tissue, such as in emphysema or pneumothorax. In the abdominal assessment, hyperresonance is generally not an expected finding and may indicate gaseous distension.
Choice B rationale
Flatness is a dull, very soft sound with a short duration, usually heard over dense tissues such as bone or muscle. In the abdomen, flatness is not a typical percussion sound and might be elicited over a large tumor or organomegaly.
Choice C rationale
Dullness is a thud-like sound with a medium intensity and duration, typically heard over solid organs such as the liver, spleen, or a distended bladder. In the abdominal assessment, dullness is an expected finding over these organs.
Choice D rationale
Resonance is a hollow sound of moderate duration and low pitch, typically heard over normal lung tissue. Resonance is not an expected percussion sound in the abdominal assessment; tympany and dullness are the predominant sounds.
Choice E rationale
Tympany is a drum-like sound with high pitch and longer duration, commonly heard over air-filled structures such as the stomach and intestines. Tympany is the predominant percussion sound expected over most of the abdomen due to the presence of gas in the gastrointestinal tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Normoactive bowel sounds are the typical, intermittent gurgling sounds heard during a bowel assessment, indicating normal peristalsis and intestinal activity. The absence of any sounds for 30 seconds suggests a significant reduction or cessation of this activity, which is not consistent with normoactive findings.
Choice B rationale
Hypoactive bowel sounds are characterized by infrequent and faint gurgling sounds, indicating a decrease in intestinal motility. While a pause of 30 seconds without any sounds might precede hypoactive sounds, the complete absence of sounds for this duration is more indicative of a further reduction in bowel activity than simply hypoactivity.
Choice C rationale
Absent bowel sounds are documented when no bowel sounds are heard after listening in each of the four abdominal quadrants for a specified period, typically ranging from 2 to 5 minutes per quadrant. A 30-second period without any sounds in one area is a significant finding that should be documented as absent in that specific quadrant, warranting further assessment.
Choice D rationale
Hyperactive bowel sounds are loud, high-pitched, and frequent gurgling sounds, often described as "borborygmi" or stomach rumbling. These sounds indicate increased intestinal motility, which is the opposite of the finding of no bowel sounds for 30 seconds.
Correct Answer is B
Explanation
Choice A rationale
Chicken is poultry, and a lacto-ovo vegetarian diet excludes all meat, poultry, and fish. Grilled eggplant and cheese are acceptable as they are vegetables and dairy products, respectively. However, the presence of chicken makes this choice incorrect for a lacto-ovo vegetarian.
Choice B rationale
Boiled eggs are permitted in a lacto-ovo vegetarian diet as it includes eggs and dairy. Chocolate milk is also allowed as it is a dairy product. This choice aligns with the definition of a lacto-ovo vegetarian diet, which includes dairy and eggs but excludes meat, poultry, and fish.
Choice C rationale
Oysters are shellfish, and turkey is poultry, both of which are excluded from a lacto-ovo vegetarian diet. Yogurt is a dairy product and is acceptable. The inclusion of oysters and turkey makes this choice incorrect.
Choice D rationale
Fish is not allowed in a lacto-ovo vegetarian diet. Milk is a dairy product and is acceptable. Poached eggs are also permitted. The presence of fish makes this choice incorrect.
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