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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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

A. Increase fiber in diet and add daily prune juice. B. Perform a digital examination for fecal impaction. C. Assess type and frequency of physical activities. D. Check bowel sounds and abdominal tenderness.

Correct Answer is D

Explanation

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

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Naxlex Comprehensive Predictor Exams

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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