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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Anorexia refers to a loss of appetite or lack of interest in food, not difficulty swallowing.
B. Aphasia is a language disorder that affects a person's ability to communicate, not related to swallowing difficulties.
C. Dysphagia is the medical term for difficulty swallowing, which can involve medications and food, potentially due to various causes like neurological conditions or structural issues.
D. Dysphasia refers to difficulty with speech or language, not directly related to swallowing difficulties.

A. Listen to the client's speech B. Ask the client to identify scented aromas C. Ask the client to clench his teeth D. Ask the client to read a Snellen chart

Correct Answer is D

Explanation

A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has difficulty swallowing medications and food. The nurse should recognize that the client is experiencing which of the following:

Correct Answer is C

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is D

Explanation

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