A nurse inspects the abdomen for skin color, surface characteristics, and surface movement. What part of the abdominal assessment does the nurse perform next?
Percussion for tones in all four quadrants
Auscultation of the bowel sounds in all four quadrants.
Deep palpation for masses or aortic pulsation
Light palpation for tenderness and muscle tone.
The Correct Answer is B
The clinical sequence for abdominal assessment is modified to inspection, auscultation, percussion, and palpation. This specific order prevents the mechanical stimulation of the gastrointestinal tract, which can induce pseudo-borborygmi. Maintaining this sequence ensures that bowel sounds are representative of the patient's baseline physiological state.
A. Percussion for tones in all four quadrants: Percussion involves tapping the abdominal wall to elicit sounds, which can physically disturb the bowel and alter motility. It should only be performed after auscultation has been completed. Performing it next would violate the established diagnostic sequence for an abdominal exam.
B. Auscultation of the bowel sounds in all four quadrants: This is the mandatory second step in abdominal assessment following inspection. It allows the nurse to listen to natural peristaltic activity before the abdomen is palpated or percussed. This ensures the most accurate representation of the patient's current bowel activity.
C. Deep palpation for masses or aortic pulsation: Deep palpation is the final step of the abdominal examination because it is the most invasive and potentially painful. It can cause significant guarding or alter the sounds heard during auscultation. It must never precede auscultation or percussion in a standard assessment.
D. Light palpation for tenderness and muscle tone: While less invasive than deep palpation, light palpation still involves physical contact that can change the frequency of bowel sounds. It is performed after auscultation and percussion have provided enough clinical data. It serves to identify superficial masses and areas of discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The Glasgow Coma Scale (GCS) provides a standardized, objective framework for assessing a patient's level of consciousness. It evaluates three distinct categories of neurological function: eye opening, verbal response, and motor response. The resulting sum score allows clinicians to track neurological improvement or deterioration in cases of traumatic brain injury.
A. Blood pressure: Vital signs like blood pressure are essential components of a general physical assessment but are not included in the GCS score. While hypotension can cause a decrease in GCS due to poor cerebral perfusion, blood pressure is a hemodynamic rather than a primary neurological response metric.
B. Verbal response: This component assesses the patient's ability to communicate and their level of orientation. Scores range from 1 (no response) to 5 (oriented conversation). It is a fundamental part of the GCS used to evaluate the integration of cognitive and linguistic functions.
C. Motor response: This is often the most significant predictor of outcome in neurological injuries. It measures the patient's ability to follow commands or their reaction to stimuli, ranging from 1 to 6. It is a core assessment within the three-part GCS framework.
D. Eye opening: This category assesses the arousal system and the function of the brainstem. It is graded from 1 to 4, ranging from no opening to spontaneous eye opening. It is the third essential component required to calculate a total GCS score.
E. Pulse rate: Like blood pressure, pulse rate is a vital sign used to monitor cardiovascular and autonomic status. While a slow or fast pulse can provide clues to neurological status (such as Cushing’s triad), it is not a parameter measured within the Glasgow Coma Scale itself.
Correct Answer is A
Explanation
Tympany is a high-pitched, drum-like sound produced by percussing over air-filled viscera such as the stomach and intestines. It is the dominant sound in a healthy abdomen due to the presence of intraluminal gas. Areas of dullness are typically restricted to solid organs like the liver or a full bladder.
A. Tympany over all quadrants: Since the majority of the abdominal cavity is occupied by gas-containing loops of small and large intestines, tympany should be the most prevalent sound. It indicates a normal distribution of air within the digestive tract. This is the expected finding in a healthy patient.
B. Dull sounds over the stomach and resonant sounds over the bladder: The stomach is an air-filled sac and should produce tympany, not dullness, unless it is completely full of food. A distended bladder produces dullness due to fluid, while resonance is typically heard over the lungs. This description is anatomically and acoustically incorrect.
C. Resonance over the upper quadrants and dullness in the lower quadrants: Resonance is a sound found over healthy lung tissue and is not a standard abdominal percussion note. Dullness in the lower quadrants would suggest a massive fluid collection or pregnancy rather than a normal state. This does not represent a healthy abdomen.
D. Dull sounds over all quadrants: Widespread dullness indicates the absence of air and would be highly pathological, suggesting massive ascites, a large tumor, or pregnancy. In a normal assessment, dullness is only expected over the liver in the right upper quadrant. It is not the predominant sound.
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