The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?
Auscultate for another 4 minutes.
Listen for another minute just to be sure.
Contact the physician as this is a surgical emergency.
Listen posteriorly for enhanced bowel sounds.
The Correct Answer is B
The appropriate next step would be to auscultate for another 4 minutes. The absence of bowel sounds for one minute does not necessarily indicate a surgical emergency, as bowel sounds may be affected by various factors such as the client's diet, medications, and level of activity. Listening for another minute may not provide enough information to make an accurate assessment, so it is recommended to listen for a longer period. If after the additional 4 minutes, there are still no bowel sounds heard, the nurse should notify the physician to further evaluate the client. Listening posteriorly may also provide additional information, but it should be done after the nurse has completed listening to all four quadrants of the abdomen anteriorly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The nurse would describe this as tinnitus, which is a sensation of hearing sound when no external sound is present. Tinnitus is commonly described as ringing in the ears, but can also be perceived as buzzing, humming, hissing, or other sounds. Tinnitus can be caused by a variety of factors, including age-related hearing loss, exposure to loud noises, ear infections, certain medications, and underlying medical conditions such as high blood pressure, thyroid disorders, or head and neck injuries. It is important for the patient to see a healthcare provider to determine the underlying cause and appropriate treatment.
Correct Answer is ["A","B","C"]
Explanation
Prostate enlargement is not directly assessed through an anal examination.
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