A nurse assesses a patient’s abdomen. Which examination technique would aid the nurse in determining whether gas (air) in the bowel is causing distention rather than constipation?

Inspection

Auscultation

Percussion

Palpation

Answer and Explanation

The Correct Answer is C

Choice A reason: Inspection visually assesses abdominal shape and distention but cannot differentiate gas from constipation, as both may cause distention. It lacks the specificity to identify the cause, making it less effective for this purpose.

Choice B reason: Auscultation assesses bowel sounds but cannot directly distinguish gas from constipation. Hyperactive sounds may suggest gas, but this is indirect, and constipation can also alter sounds, making this less specific than percussion.

Choice C reason: Percussion produces a tympanic sound over gas-filled areas, indicating air in the bowel, versus a dull sound over solid masses like feces in constipation. This directly differentiates the cause of distention, making it the correct technique.

Choice D reason: Palpation assesses tenderness or masses but cannot reliably distinguish gas from constipation, as both may feel firm or distended. It lacks the specificity of percussion’s auditory cues, making it less effective for this purpose.

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Correct Answer is B

Explanation

Choice A reason: Checking the ophthalmoscope’s light source is unnecessary unless the device malfunctions. The red glow is a normal finding, reflecting light off the retina’s blood vessels, not indicating equipment issues, making this an inappropriate action.

Choice B reason: The red glow, or red reflex, is a normal finding during ophthalmoscopy, caused by light reflecting off the vascular retina. It indicates a clear optical pathway, ruling out opacities like cataracts, making this the correct action to document as normal.

Choice C reason: An opacity in the lens or cornea (e.g., cataract or corneal scar) would block the red reflex, causing a dark or absent glow. The presence of a red glow indicates a clear media, making this suspicion incorrect.

Choice D reason: Stopping the exam and referring the patient is unwarranted, as the red glow is a normal finding. Referral is only needed for abnormal findings like absent reflex or opacities, making this an unnecessary and incorrect action.

A. “When was your last mammography?” B. “Do you receive annual breast examination?” C. “How often do you perform breast self-examination?” D. “How often do you visit your physician?”

Correct Answer is C

Explanation

Choice A reason: Asking about the last mammography focuses on screening, not the technique or frequency of self-examination. Inquiring about self-exam frequency ensures the patient performs it regularly, so this is incorrect for ensuring proper practice.

Choice B reason: Annual breast exams are clinical, but this question doesn’t confirm the patient patient performs self-exams. Asking about self-examination frequency directly addresses the practice, so this is not the best statement.

Choice C reason: Asking how often the patient performs breast self-examination confirms whether they do it regularly (e.g., monthly) and opens discussion on technique, ensuring correct practice. This is the best statement, so it’s correct.

Choice D reason: Physician visits are unrelated to self-performing self-examination at home. Frequency of breast self-exams is key to ensuring compliance, so this is incorrect for the nurse’s goal.

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A nurse assesses a patient’s abdomen. Which examination technique would aid the nurse in determining whether gas (air) in the bowel is causing distention rather than constipation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. Based on this finding, what should the nurse do?

Correct Answer is B

Explanation

Which is the best statement by the nurse to ensure that a patient is performing breast self-examination correctly?

Correct Answer is C

Explanation

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