When assessing a client’s abdomen, the nurse uses auscultation to assess for which possible finding?

Guarding.

Ascites.

Striae.

Bruits.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Guarding refers to voluntary or involuntary muscle contraction of the abdominal wall in response to pain or inflammation. This is assessed through palpation, where the nurse feels for muscle rigidity, not through auscultation, which involves listening to internal sounds.

Choice B rationale

Ascites, the accumulation of fluid in the peritoneal cavity, is primarily detected through inspection (distended abdomen), palpation (fluid wave, shifting dullness), and percussion. Auscultation is not the primary method for identifying the presence of free fluid in the abdominal cavity.

Choice C rationale

Striae, commonly known as stretch marks, are linear streaks or bands on the skin resulting from rapid stretching. These are visual findings, assessed through inspection of the skin surface, and cannot be detected by auscultation, which relies on sound perception.

Choice D rationale

Bruits are abnormal vascular sounds, often described as swishing or humming, produced by turbulent blood flow through a narrowed or dilated artery. Auscultation with a stethoscope is the appropriate technique to detect these sounds over abdominal arteries, indicating potential vascular abnormalities.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale

Headaches are a common symptom with various etiologies, including hypertension, stress, or dehydration, but they are not a classic or specific indicator of heart failure exacerbation. While a client with heart failure might experience headaches, it does not directly confirm the worsening of cardiac function or fluid overload. Therefore, it is not a primary diagnostic criterion for exacerbation.

Choice B rationale

Intercostal retractions signify increased work of breathing due to airway obstruction or lung compliance issues, often observed in severe respiratory distress associated with heart failure exacerbation. This physiological response indicates significant effort to move air, suggesting pulmonary congestion and reduced lung capacity secondary to fluid accumulation in the alveoli. It is a critical objective sign.

Choice C rationale

Peripheral edema, particularly in the lower extremities, is a hallmark sign of right-sided heart failure. It results from increased hydrostatic pressure in the capillaries, forcing fluid into the interstitial spaces due to the heart's inability to effectively pump blood forward. This fluid retention confirms systemic volume overload, indicative of worsening heart failure.

Choice D rationale

Dyspnea, or shortness of breath, is a cardinal symptom of heart failure, especially when exacerbated. It arises from pulmonary venous congestion and increased fluid in the interstitial spaces of the lungs, impairing gas exchange. The sensation of breathlessness, particularly with exertion or at rest, directly reflects compromised cardiac output and fluid overload.

Choice E rationale

Jugular venous distension (JVD) is a direct clinical manifestation of elevated central venous pressure, a key indicator of right-sided heart failure and fluid volume overload. When the heart struggles to pump blood effectively, blood backs up into the venous system, causing the jugular veins to become visibly engorged, confirming an exacerbation.

A. Gingival inflammation. B. White, curd-like lesions. C. Buccal mucosa ulceration. D. Fruity odor of the breath.

Correct Answer is D

Explanation

Choice A rationale

Gingival inflammation, or gingivitis, is a common oral finding indicative of mild to moderate periodontal disease. While it requires follow-up for proper oral hygiene and management, it does not typically represent an immediate, acute threat to a client's health requiring urgent intervention. It suggests bacterial accumulation and host inflammatory response.

Choice B rationale

White, curd-like lesions in the mouth are highly characteristic of oral candidiasis (thrush), a fungal infection caused by *Candida albicans*. In adults, especially those who are immunocompromised or on certain medications, this can spread, indicate systemic illness, or cause significant discomfort and nutritional compromise. It warrants immediate assessment and treatment.

Choice C rationale

Buccal mucosa ulceration, while causing discomfort and potentially indicating local trauma, viral infection, or systemic conditions, is not typically an immediate emergency unless associated with severe pain, bleeding, or signs of rapid progression. Isolated ulcers usually heal spontaneously or with symptomatic treatment.

Choice D rationale

A fruity odor of the breath, often described as a sweet, acetone-like smell, is a hallmark sign of diabetic ketoacidosis (DKA). This is a life-threatening metabolic emergency characterized by severe hyperglycemia, acidosis, and ketone body production, requiring immediate medical intervention to prevent severe complications like cerebral edema and coma.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When assessing a client’s abdomen, the nurse uses auscultation to assess for which possible finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm(s) to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

When assessing a client's mouth, which finding requires immediate follow-up by the nurse?

Correct Answer is D

Explanation

The nurse plans to assess a client's ability to think abstractly. Which task or statement is likely to provide the best information about the client's abstract thinking?

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. Which does this finding indicate?

An older adult male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?