The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?
Absolute dullness.
Absent sounds.
Pain.
Musical and drum like.
The Correct Answer is D
A. Absolute dullness: This typically indicates fluid or a mass in the abdomen and is not a normal finding.
B. Absent sounds: Complete absence of bowel sounds can be a sign of an obstruction or ileus.
C. Pain: Pain during percussion suggests inflammation or irritation in the underlying organs.
D. Musical and drum like sounds: These are normal bowel sounds produced by gas and fluid movement within the intestines.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.
B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.
C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.
D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.
Correct Answer is C
Explanation
A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.
B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.
C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.
D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.
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