While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Hyperactive bowel sounds.

A minor variation.

Normal borborygmic sounds.

Possible renal artery stenosis.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Hyperactive bowel sounds are incorrect. Hyperactive bowel sounds refer to increased or loud gurgling noises heard during auscultation of the abdomen, which may indicate increased intestinal motility or bowel obstruction. These sounds are typically high-pitched and occur in various abdominal quadrants, rather than specifically in the upper midline area.
Choice B Reason:
A minor variation is incorrect. A minor variation in abdominal sounds may occur and could be considered normal. However, a low-pitched blowing sound in the upper midline area is not typically categorized as a minor variation but rather as an abnormal finding that warrants further investigation.
Choice C Reason:
Normal borborygmic sounds is incorrect. Borborygmic refers to the normal rumbling or gurgling sounds produced by the movement of gas and fluid in the intestines. While borborygmic sounds may be heard during abdominal auscultation, they are typically described as high-pitched and occur in various abdominal quadrants, not specifically in the upper midline area. Therefore, they are not likely to be the indication of the finding described in the scenario.
Choice D Reason:
Possible renal artery stenosis is correct. Renal artery stenosis is a condition characterized by the narrowing of one or both renal arteries, which can lead to reduced blood flow to the kidneys. When auscultating the abdomen, a low-pitched blowing sound (bruit) heard over the upper midline area could indicate turbulence of blood flow in the renal arteries. This bruit is typically associated with renal artery stenosis and reflects the increased velocity of blood passing through a narrowed arterial lumen. Identifying a renal artery bruit during abdominal auscultation warrants further investigation, such as imaging studies or referral to a specialist for evaluation and management of renal artery stenosis.

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Correct Answer is C

Explanation

Choice A Reason:

Ask about recent abdominal trauma: in this case, the depressed umbilicus is a normal finding, so no further action related to trauma assessment is necessary.

Choice B Reason:

Palpate the area for masses: Palpating the area for masses is a good practice during abdominal assessments. However, in the context of a depressed umbilicus, this finding is not indicative of an abnormal mass. Therefore, palpation is not specifically warranted.

Choice C Reason:

Document the normal finding: Correct! A depressed umbilicus that lies below the surface of the abdomen is considered a normal variation. Documenting this finding ensures accurate and comprehensive assessment documentation.

Choice D Reason:

Observe the midline for scarring: While observing the midline for scarring is relevant in some situations (such as assessing for surgical scars), it’s not directly related to the depressed umbilicus. Therefore, this action is not necessary based on the specific finding described.

A. Reach under a gown to listen and take care that no clothing rubs on the stethoscope B. Ensure the room is as quiet as possible C. Keep the examination room warm, and warm the stethoscope D. Document the roaring and crackles E. Wet the chest hair before auscultating

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

Explanation

Choice A Reason:
This option can help minimize clothing-related artifacts that may interfere with auscultation. Ensuring that the stethoscope is in direct contact with the skin allows for better transmission of sounds
Choice B Reason:
Ensuring the room is as quiet as possible is appropriate. Background noise can interfere with the clarity of auscultatory sounds. Ensuring a quiet environment helps reduce external interference and improves the nurse's ability to accurately hear and interpret the sounds.
Choice C Reason:
Keeping the examination room warm, and warm the stethoscope is appropriate. Cold temperatures can cause vasoconstriction and muscle tension, leading to increased tension in the skin and subcutaneous tissues, which may affect the quality of auscultatory sounds. Keeping the examination room warm and warming the stethoscope helps minimize this effect, ensuring clearer auscultation.
Choice D Reason:
Document the roaring and crackles is inappropriate. Documenting auscultatory findings such as roaring and crackles is important for clinical assessment and documentation but does not mitigate artifacts during auscultation. It is crucial to focus on optimizing the auscultation environment and technique to ensure accurate interpretation of sounds.
Choice E Reason:
Wetting the chest hair before auscultating is appropriate. Chest hair can create friction and produce artifacts during auscultation, particularly when using a stethoscope. Wetting the chest hair helps reduce friction and minimize artifacts, allowing for clearer auscultatory sounds.

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While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. What action should the nurse take in response to this observation?

Correct Answer is C

Explanation

The client is a 35-year-old male with no history of any medical conditions is in the clinic for an annual physical. Exhibits Nurse analyzes the findings. What can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

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

Explanation

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