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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While physical touch, such as placing a hand on the client’s shoulder, can sometimes be reassuring, it might not always be appropriate or welcomed, especially if the client is already expressing frustration or anger. It’s important to assess the client's comfort with physical contact before proceeding with such gestures.
B. Ignoring the client's angry outburst is not advisable because it fails to acknowledge the client’s feelings and may escalate their frustration. Addressing emotional responses is crucial in maintaining a therapeutic relationship and ensuring that the client feels heard and respected.
C. This response is the best choice because it acknowledges the client’s emotional state and invites them to share their feelings. By addressing the client's anger directly and expressing a willingness to listen, the nurse helps to validate the client’s emotions and opens the door for a more productive dialogue.
D. While this response acknowledges the client's feelings, it might come across as dismissive of their immediate needs and could imply that their concerns are not worth addressing at this time. It also does not actively engage with the client's emotions or attempt to resolve the frustration.
Correct Answer is B
Explanation
A. Musical sounds or high-pitched, tinkling noises are not typically considered normal bowel sounds. These types of sounds might indicate increased bowel activity or bowel obstruction. They are usually associated with abnormal conditions like bowel obstruction or early signs of a bowel problem.
B. This description is consistent with normal bowel sounds. Bowel sounds are usually described as clicks and gurgles that occur irregularly. They are typically heard as a mix of low to moderate pitched sounds and are a normal part of the gastrointestinal activity. Normal bowel sounds usually have an irregular pattern and may vary in frequency and intensity.
C. High-pitched tinkling sounds are not considered normal and could indicate abnormal bowel activity. These sounds are often associated with increased intestinal motility, which can occur in conditions such as bowel obstruction. They suggest that the bowel is more active than normal, which could be a sign of an underlying problem.
D. Prolonged gurgling sounds can sometimes be heard in cases of increased bowel activity but are not typical of normal bowel sounds. Normal bowel sounds are generally intermittent and irregular rather than prolonged. Prolonged gurgles might suggest issues like increased bowel activity or a bowel condition requiring further investigation.
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