The client is brought into the emergency room (ER) by paramedics with blunt trauma to the left upper side of the abdomen due to a motor vehicle accident. The ER nurse knows what organ is most likely impacted.

appendix

left ureter

left lobe of liver

sigmoid colon

Answer and Explanation

The Correct Answer is C

A. Appendix: Located in the right lower quadrant, the appendix is unlikely to be impacted in left upper quadrant trauma.

B. Left ureter: The left ureter is located lower in the abdomen along the flank area and is not directly impacted in the left upper quadrant.

C. Left lobe of liver: The liver’s left lobe extends into the left upper quadrant, making it a likely organ to be impacted in blunt trauma to this area, particularly given its large size and location near the abdominal wall.

D. Sigmoid colon: Positioned lower in the left lower quadrant, the sigmoid colon is less likely to be affected by left upper abdominal trauma.

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Correct Answer is C

Explanation

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.

A. When did your pain symptoms begin?" B. "Do you think you know what caused the swelling? C. "What brings you to the clinic today?" D. "Can you go over what you said about nothing relieving the pain?

Correct Answer is A

Explanation

A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.

B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.

C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.

D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.

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The client is brought into the emergency room (ER) by paramedics with blunt trauma to the left upper side of the abdomen due to a motor vehicle accident. The ER nurse knows what organ is most likely impacted.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The absence of bowel sounds is established after listening for:

Correct Answer is C

Explanation

The nurse is conducting a focused assessment of a client who is experiencing pain. Which question should the nurse ask the client?

Correct Answer is A

Explanation

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