The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Listen for another minute just to be sure

Contact the physician as this is a surgical emergency.

Auscultate for another 4 minutes

Listen posteriorly for enhanced bowel sounds

Answer and Explanation

The Correct Answer is C

A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.

B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.

C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.

D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.

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Correct Answer is D

Explanation

A) "Have you ever had any surgeries?": While this question is important, it is more specific and may not provide the comprehensive context needed to guide the interview. It could lead to a narrow focus on past surgical history without addressing the client’s current health status or concerns.

B) "Tell me about any medical problems that you have had.": This question is useful but lacks the immediate relevance to the client's current situation. It may prompt the client to recount past issues rather than focusing on their current health needs and reasons for seeking care.

C) "Tell me about any medications you are currently taking.": This is an essential aspect of health history, but like the previous options, it doesn't address the client’s immediate concerns or symptoms that may guide the rest of the interview.

D) "Tell me why you are seeking care today.": This question is the most effective starting point as it directly addresses the client’s current health issue or concern. Understanding the reason for seeking care helps the nurse prioritize topics, gather relevant information, and tailor the rest of the health history interview to the client’s specific needs, making it a crucial guide for further questioning.

A. Increased muscle weakness B. Pronounced muscle atrophy C. Diminished visual acuity D. Impaired cognitive reasoning

Correct Answer is A

Explanation

A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.

B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.

C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.

D) Impaired cognitive

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The nurse auscultates the client's abdomen for 1 minute and does not hear anybowel sounds. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is beginning a health history interview. Which of the following will best guide the rest of the health history interview?

Correct Answer is D

Explanation

The nurse is caring for a patient with a new diagnosis of Guillian-Barré syndrome. What does the nurse expect to find when assessing this patient?

Correct Answer is A

Explanation

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