Which of the following are normal findings you should find during a physical exam? Select all that apply

Jugular vein flattens when a patient sits up.

A swooshing sound is normally heard when auscultating a carotid artery.

Upon palpation, a lymph node is normally tender.

Normal sitting posture involves some degree of rounding of the shoulders.

Normally there is no bulging within the intercostal spaces during breathing.

Answer and Explanation

Correct Answer : A,D,E

Recognizing normal versus abnormal findings is critical in identifying early signs of illness, ensuring accurate documentation, and promoting prompt interventions when needed.

Rationale for correct answers:

1. Jugular vein flattens when a patient sits up: This is a normal finding. When a patient is sitting upright, gravity reduces venous return, causing the jugular vein to flatten or become non-distended.

4. Normal sitting posture involves some degree of rounding of the shoulders: Slight rounding of the shoulders is a normal postural variation, especially in older adults. However, marked kyphosis (extreme curvature) would be abnormal.

5. Normally there is no bulging within the intercostal spaces during breathing: In a healthy individual, intercostal spaces remain flat or slightly retracted during normal breathing. Bulging of the intercostal spaces may indicate air trapping, increased intrathoracic pressure, or respiratory distress.

Rationale for incorrect answers:

2. A swooshing sound is normally heard when auscultating a carotid artery: A swooshing sound, known as a bruit, is abnormal. It suggests turbulent blood flow, often caused by atherosclerosis or narrowing of the artery. A normal carotid auscultation should be silent, without bruit.

3. Upon palpation, a lymph node is normally tender: Normal lymph nodes are usually non-tender, soft, movable, and small. Tender lymph nodes suggest infection or inflammation, while hard or fixed nodes may raise concern for malignancy.

Take home points:

Silence is normal when auscultating carotid arteries; a bruit signals vascular abnormality.
Understanding subtle normal variations, such as minor postural changes or lymph node characteristics, helps distinguish pathology from healthy findings.

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Free Nursing Study Resources

Correct Answer is C

Explanation

After surgery, especially major abdominal procedures like a hysterectomy, patients are closely monitored for signs of postoperative complications. Nurses play a critical role in identifying early signs of respiratory depression, hemorrhage, infection, or impaired circulation.

Rationale for correct answers:

3. Respiratory rate of 8 breaths/min is below the normal range (12-20 breaths/min) and may indicate respiratory depression, which is a serious and potentially life-threatening complication, particularly after receiving opioids for postoperative pain control.

Rationale for incorrect answers:

1. Auscultation of an apical heart rate of 76 is within the normal adult range (60-100 bpm) and is expected postoperatively, especially when the patient is resting and under pain control.

2. Absence of bowel sounds on abdominal assessment: It is expected for bowel sounds to be absent or hypoactive immediately after abdominal surgery due to the effects of anesthesia and surgical manipulation of the intestines.

4. Palpation of dorsalis pedis pulses with strength of +2: A pulse strength of +2 is normal and indicates adequate peripheral circulation. There is no indication of vascular compromise, and this finding is reassuring, not alarming.

Take home points:

Always assess respiratory rate and depth closely after surgery, especially within the first few hours when opioid analgesics can depress respiratory drive.
Not all abnormal findings require urgent intervention postoperatively-learn to distinguish expected effects of surgery (like decreased bowel sounds) from dangerous signs (like respiratory depression).

A. Bruit over the aorta B. Absence of bowel sounds for 60 seconds C. Continuous bowel sounds over the ileocecal valve D. A completely irregular pattern of bowel sounds

Correct Answer is A

Explanation

Auscultation of the abdomen is a vital step in assessing gastrointestinal and vascular function. It helps detect bowel motility, vascular abnormalities, and potential obstructions. Normally, bowel sounds are present and irregular, occurring every 5-15 seconds.

Rationale for correct answer:

1. Bruit over the aorta: A bruit is a swishing or whooshing sound heard over an artery, indicating turbulent blood flow-often due to aneurysm or arterial stenosis. A bruit over the abdominal aorta can signal an abdominal aortic aneurysm (AAA), a potentially life-threatening condition.

Rationale for incorrect answers:

2.Absence of bowel sounds for 60 seconds: Bowel sounds can be irregular, and 60 seconds is not enough time to confirm absence. To declare absent bowel sounds, the nurse must listen in all four quadrants for a full 5 minutes.

3. Continuous bowel sounds over the ileocecal valve: The ileocecal valve, located in the right lower quadrant, is often the most active region of the abdomen. Continuous or frequent bowel sounds here may be normal, especially after eating.

4. A completely irregular pattern of bowel sounds: Bowel sounds are normally irregular in rhythm and timing. They can vary in pitch and frequency, and this irregularity is a normal finding.

Take home points

A bruit over the abdominal aorta is an abnormal vascular sound and may indicate a serious condition like an abdominal aortic aneurysm. It should be reported immediately.
Bowel sounds are naturally irregular-their absence must be confirmed by listening for a full 5 minutes before reporting.

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Which of the following are normal findings you should find during a physical exam? Select all that apply

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up?

Correct Answer is C

Explanation

After auscultating the abdomen, the nurse should report which finding to the primary care provider?

Correct Answer is A

Explanation

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