While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Soft tissue.

Gas.

Intestinal mass.

Full bladder.

Answer and Explanation

The Correct Answer is B

A.   Soft tissue, such as the liver or spleen, typically produces a dull sound on percussion, not a high- pitched musical sound. Soft tissue is more associated with a dullness because it is denser compared to the surrounding air or fluids.
B.   Gas in the gastrointestinal tract often produces a musical or high-pitched sound on percussion, known as tympany. This sound occurs because gas is less dense than other abdominal contents and resonates with a high pitch. Tympany is the most common sound heard when percussing over the stomach and intestines.
C.   An intestinal mass, depending on its size and location, may produce a dull or a combination of dull and tympanic sounds. However, it is not typically associated with a high-pitched musical sound. Percussion over an intestinal mass would likely be dull rather than musical.
D.   A full bladder typically produces a dull sound on percussion, not a musical high-pitched sound. A dull sound indicates the presence of a solid or fluid-filled structure, such as a full bladder.

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Correct Answer is D

Explanation

A. Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B. Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C. A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D. Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

A. Measure the degree of skin elasticity. B. Palpate the area for warmth and swelling. C. Determine the client's oxygen saturation. D. Observe the appearance of the nailbeds.

Correct Answer is B

Explanation

A. Skin elasticity is assessed by pinching the skin to see how quickly it returns to its normal position, which is often done to evaluate hydration status or the presence of dehydration. While skin elasticity is an important overall assessment of skin health, it is not directly related to the assessment of erythema.
B. Palpating the erythematous area for warmth and swelling is a crucial follow-up assessment. Erythema (redness of the skin) can be a sign of inflammation or infection, and the presence of warmth and swelling can help determine if the area is inflamed or if there might be an underlying infection.
C. Oxygen saturation measurements assess the level of oxygen in the blood, typically using a pulse oximeter. While oxygen saturation is important for assessing overall respiratory and circulatory health, it is not directly related to evaluating the cause or characteristics of erythema. Therefore, this would not be the most relevant follow-up assessment for a red area on the skin.
D. Observing the appearance of the nailbeds can provide information about overall circulation and oxygenation, but it is not directly related to assessing a localized area of erythema on the skin. Changes in the nailbeds can indicate systemic conditions but would not provide specific information about the erythematous area in question.

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While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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