A nurse is precepting a new graduate nurse on the telemetry unit. The new graduate nurse is preparing to perform an abdominal assessment on a hospitalized client without a history of gastrointestinal abnormalities. Click to indicate the corresponding number for each of the following assessment techniques in order of performance.

Percussion

Inspection

Palpation

Auscultation

Answer and Explanation

The Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}

Assessment Technique	1	2	3	4
Percussion				✅
Inspection	✅
Palpation			✅
Auscultation		✅

Rationale:

Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

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Correct Answer is B

Explanation

A. Decreased adaptation to darkness: This change is related to decreased rod function but is not responsible for presbyopia.

B. Loss of lens elasticity: Correct. Presbyopia is caused by the age-related loss of elasticity in the lens, which reduces the ability to focus on near objects.

C. Decreased distance vision abilities: This may occur with other conditions like myopia but does not cause presbyopia.

D. Degeneration of the cornea: This can affect vision but is not responsible for presbyopia.

A. Nerve degeneration in the inner ear B. Cilia becoming coarse and stiff C. Scarring of the tympanic membrane D. Atrophy of the apocrine glands

Correct Answer is A

Explanation

A. Nerve degeneration in the inner ear: This describes presbycusis, a common age-related hearing loss due to degeneration of the cochlea or auditory nerve, often affecting the ability to hear high-frequency sounds and distinguish sounds in noisy environments.
B. Cilia becoming coarse and stiff: This contributes to conductive hearing loss but does not typically cause difficulty localizing sounds.
C. Scarring of the tympanic membrane: This may result from repeated infections but usually causes conductive hearing loss.
D. Atrophy of the apocrine glands: This affects sweat production, not hearing.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

Correct Answer is B

Explanation

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

Correct Answer is A

Explanation

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a:

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

When assessing the abdomen most health care providers divide the abdomen into how many sections?