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 C
Explanation
A. 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. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
B. 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. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
C. 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. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
D. 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. Lightly palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.
Correct Answer is D
Explanation
A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.
B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.
C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.
D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.
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