During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Subjective vertigo.

Tinnitus.

Dizziness.

Objective vertigo.

Answer and Explanation

The Correct Answer is D

A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.

B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.

C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.

D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.

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Correct Answer is B

Explanation

A. 1 minute: This is not the correct duration for assessing bowel sounds.

B. 2 minutes each quadrant: Bowel sounds should be auscultated for at least 2 minutes per quadrant before determining that they are absent.

C. 5 minutes: Listening for 5 minutes is excessive and typically unnecessary unless there is concern about a complete absence of bowel sounds.

D. 10 minutes: 10 minutes is also too long for auscultation unless specifically indicated by clinical findings, like suspected paralytic ileus.

A. "We need to determine the areas of tenderness before using percussion and palpation." B. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." C. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." D. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

Correct Answer is C

Explanation

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

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During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Correct Answer is C

Explanation

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

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