A nurse performs an abdominal assessment on 4 patients. Which of the following would be considered a normal abdominal assessment?
Abdomen nondistended, soft, with active bowel sounds in all four quadrants.
Abdomen distended, firm, with hypoactive bowel sounds in all four quadrants.
Abdomen distended, soft, with hyperactive bowel sounds in all four quadrants.
Abdomen nondistended, firm, with hypoactive bowel sounds in all four quadrants.
The Correct Answer is A
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
Correct Answer is D
Explanation
Choice A: Holding the enema for only 5 minutes may not provide enough time for the mineral oil to soften the stool and facilitate a bowel movement.
Choice B Holding the enema for 60 minutes is unnecessary and can lead to discomfort and difficulty for the patient.
Choice C Holding the enema for only 1 minute is too short for the mineral oil to be effective in softening the stool.
Choice D Encouraging the patient to hold the mineral oil enema for a minimum of 15 minutes allows sufficient time for the oil to work on the stool and improve the chances of a successful bowel movement.
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