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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Decrease in tear production: This is a common age-related change and is not considered abnormal.

B. Unequal pupillary constriction: Correct. Unequal pupillary constriction (anisocoria) is not normal and may indicate neurological issues.

C. Loss of outer eyebrow hair: This is a normal age-related change due to decreased hair follicles.

D. Arcus senilis: This is a common finding in older adults and is typically benign, caused by lipid deposits around the cornea.

A. Percussion B. Inspection C. Palpation D. Auscultation

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}

Explanation

Assessment Technique	1	2	3	4
Percussion				✅
Inspection	✅
Palpation			✅
Auscultation		✅

Rationale:

Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal?

Correct Answer is B

Explanation

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}

Explanation

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