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Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

Warm the stethoscope before auscultating

Have the patient bend their knees

Expose only the abdomen for examination

Have the patient empty his/her bladder

Answer and Explanation

The Correct Answer is D

A. Warming the stethoscope: Improves comfort but is not the first step.

B. Bending the knees: Helps relax abdominal muscles but is done after bladder emptying.

C. Exposing only the abdomen: Ensures privacy but does not affect comfort as much as an empty bladder.

D. Emptying the bladder relieves pressure and discomfort, allowing for a thorough and accurate examination.

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Correct Answer is B

Explanation

A. 1 minute: This is not the correct duration for assessing bowel sounds.

B. 2 minutes each quadrant: Bowel sounds should be auscultated for at least 2 minutes per quadrant before determining that they are absent.

C. 5 minutes: Listening for 5 minutes is excessive and typically unnecessary unless there is concern about a complete absence of bowel sounds.

D. 10 minutes: 10 minutes is also too long for auscultation unless specifically indicated by clinical findings, like suspected paralytic ileus.

A. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. B. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. C. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

Correct Answer is A

Explanation

A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).

B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.

C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.

D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.

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Which of the following is the first important step in helping the patient to relax for the complete abdominal examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is B

Explanation

When assessing the pupillary light reflex or PERRL (pupils, round, reactive to light), the nurse should use which technique?

Correct Answer is A

Explanation

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should:

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