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.

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Correct Answer is C

Explanation

Choice A rationale

Diminished short-term memory over the past year can be a normal part of aging or an early sign of cognitive decline. While it warrants further investigation, a gradual change like this is generally not considered an immediate medical emergency requiring urgent intervention.

Choice B rationale

Reduced fine motor skills are a common age-related change due often to conditions like osteoarthritis or essential tremor. While they can impact daily activities, unless there's a sudden, severe onset or an acute neurological deficit, it typically does not require immediate medical follow-up.

Choice C rationale

A sudden or significant change in awareness of surroundings, often termed altered mental status, is an acute neurological change that indicates an underlying physiological disturbance. This could be due to infection, metabolic imbalance, stroke, or medication side effects, necessitating immediate medical evaluation to determine the cause and intervene promptly. Normal awareness allows for accurate perception and interaction with the environment.

Choice D rationale

A negative Babinski reflex in an adult is the normal and expected finding, indicating proper functioning of the corticospinal tract. A positive Babinski reflex, where the great toe extends upwards and the other toes fan out, would be an abnormal finding in an adult, suggesting upper motor neuron damage.

A. Percuss diaphragmatic excursion. B. Auscultate the client's breath sounds. C. Observe the appearance of the thorax. D. Palpate tactile fremitus on the posterior chest.

Correct Answer is C

Explanation

Choice A rationale

Percussing diaphragmatic excursion assesses the movement of the diaphragm during respiration, reflecting lung expansion and function. While relevant to respiratory assessment, it does not directly confirm the anatomical characteristic of a barrel chest, which is a structural alteration of the thoracic cage.

Choice B rationale

Auscultating breath sounds evaluates airflow through the respiratory passages, identifying adventitious sounds like wheezes or crackles. Although individuals with a barrel chest may have altered breath sounds due to lung hyperinflation, auscultation does not directly confirm the physical presence of the barrel chest deformity itself.

Choice C rationale

Observing the appearance of the thorax allows for direct visual assessment of the anteroposterior (AP) diameter in relation to the transverse diameter. A barrel chest is characterized by an increased AP diameter, often approaching a 1: ratio, which is a key visual diagnostic criterion for this chronic respiratory condition.

Choice D rationale

Palpating tactile fremitus assesses the transmission of vibrations through the lung tissue during vocalization. While providing information about lung consolidation or obstruction, it is not a primary method for confirming the characteristic structural deformity of an increased anteroposterior diameter associated with a barrel chest.

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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