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. Lordosis B. Scoliosis C. Kyphosis D. Normal curve

Correct Answer is A

Explanation

A) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.

B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.

C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.

D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.

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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 notes an exaggerated cervical curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record?

Correct Answer is A

Explanation

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