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The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Tenderness.

Crepitus.

Thrill.

Non-tender.

Answer and Explanation

The Correct Answer is D

Answer: D

Rationale:

A) Tenderness:

Tenderness upon palpation is not considered a normal finding. It may indicate inflammation, injury, or other underlying conditions affecting the thoracic region. Tenderness requires further investigation to determine the cause and appropriate treatment.

B) Crepitus:

Crepitus, which is a crackling or popping sensation felt under the skin, is not a normal finding. It can be associated with subcutaneous air or gas, often resulting from trauma or infection. Identifying crepitus prompts further evaluation to determine the underlying issue.

C) Thrill:

A thrill is a palpable vibration or sensation over the chest, typically felt over an area of turbulent blood flow, such as a heart murmur. It is not considered a normal finding in the thoracic region and usually indicates an abnormal cardiovascular condition that requires further assessment.

D) Non-tender:

A non-tender thoracic region is considered a normal finding. Absence of tenderness upon palpation indicates no immediate signs of inflammation or injury in the thoracic area, suggesting that the palpation findings are within the expected range of normal physical examination.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

A. Aortic site. B. Sternum. C. Lung apex. D. Clavicle.

Correct Answer is C

Explanation

A) Aortic site:
The aortic site is relevant for cardiac assessment but not for auscultating breath sounds.

B) Sternum:
The sternum is a bony structure and not an optimal location to start auscultating breath sounds as it can interfere with sound transmission.

C) Lung apex:
Auscultating at the lung apex, which is located just above the clavicle, is the appropriate starting point for assessing anterior breath sounds. This ensures that the upper parts of the lungs are examined first.

D) Clavicle:
While the area near the clavicle is relevant, it is more precise to refer to the lung apex, which includes the area just above the clavicle, for starting the auscultation of breath sounds.

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The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Correct Answer is C

Explanation

Rationale:

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is C

Explanation

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