The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
"We need to determine the areas of tenderness before using percussion and palpation."
"Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination."
"Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation."
"Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."
The Correct Answer is C
A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.
B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.
C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.
D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased adaptation to darkness: This change is related to decreased rod function but is not responsible for presbyopia.
B. Loss of lens elasticity: Correct. Presbyopia is caused by the age-related loss of elasticity in the lens, which reduces the ability to focus on near objects.
C. Decreased distance vision abilities: This may occur with other conditions like myopia but does not cause presbyopia.
D. Degeneration of the cornea: This can affect vision but is not responsible for presbyopia.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
|
New Nurse Statement |
Met |
Not Met |
|
I will confirm the patient's pupil size with the scale on the side of the penlight. |
✅ |
|
|
When putting the penlight at the bridge of the nose, the eyes converge and constrict |
✅ |
|
|
I will check the patient's pupillary reflex by shining a light into their eyes. |
✅ |
|
|
When shining the penlight into the patient's eyes, their pupils should dilate |
✅ |
Rationale:
"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):
This is a correct use of the penlight to assess pupil size and document findings accurately.
"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):
This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.
"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):
This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.
"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):
This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.
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