The absence of bowel sounds is established after listening for:

2 full minutes.

1 full minute.

5 full mutes.

1 1/2 minutes.

Answer and Explanation

The Correct Answer is C

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

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Correct Answer is D

Explanation

A. Flat: A flat abdomen is level with no visible protrusions or concavities.

B. Protuberant: A protuberant abdomen appears swollen or distended, common in obesity or ascites.

C. Rounded: A rounded abdomen has a convex contour, commonly seen in children or adults with mild weight gain.

D. Scaphoid: A scaphoid abdomen appears sunken or concave, often showing visible lower ribs, suggesting malnutrition or dehydration.

A. "Most people in your situation are able to get through this." B. "Why do you think you're feeling so alone?" C. "Do you have anyone you can talk to about your diagnosis?" D. "I am so sorry about your diagnosis. You must be devastated."

Correct Answer is C

Explanation

A. "Most people in your situation are able to get through this.": This statement is dismissive and may minimize the client’s feelings, as it generalizes the experience.

B. "Why do you think you're feeling so alone?": Asking "why" may make the client feel defensive and pressured to justify their feelings, which is not therapeutic.

C. "Do you have anyone you can talk to about your diagnosis?" This response encourages the client to reflect on their support system, which may help reduce feelings of isolation. It also shows empathy and invites further conversation without making assumptions.

D. "I am so sorry about your diagnosis. You must be devastated.": While it shows sympathy, it assumes the client’s feelings and may inadvertently heighten the client’s sense of distress without providing support.

What subjective assessment information in this client situation is the most important and immediate concern for the nurse?

View Question and Answer

The absence of bowel sounds is established after listening for:

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Naxlex Comprehensive Predictor Exams

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)

Select the sequence of techniques used during an examination of the abdomen.