During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?
1 minute in the center of the abdomen.
10 minutes in each quadrant.
1 minute in each quadrant.
5 minutes in each quadrant.
None
None
The Correct Answer is D
A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.
Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.
C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Paralysis refers to the loss of muscle function in part of your body.
B. Hemiparesis is weakness on one side of the body.
C. Paraphasia is a language disorder where words get jumbled and sentences don't make sense.
D. Paresthesia is an abnormal sensation like tingling, burning, or numbness in the extremities often associated with nerve-related issues.
Correct Answer is ["B"]
Explanation
A. Stress can affect sexual performance, but it's not exclusively an internal factor. Stress can be caused by both internal and external factors.
B. Low testosterone levels are an internal factor that can significantly impact sexual performance in aging males. Testosterone decline is a natural part of aging and can affect libido and sexual function.
C. Substance use can affect sexual performance, but it's not solely an internal cause as it often involves external factors related to the intake of substances.
D. Lack of sleep affects overall health, but it can also be influenced by external factors and is not strictly an internal cause.
E. Chronic diseases such as diabetes, cardiovascular diseases, and others can have internal physiological effects that impact blood flow, nerve function, and overall health, contributing to declines in sexual performance later in life.
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