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 A

Explanation

A. A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B. A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C. While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D. Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

A. Musical intermittent sounds. B. Irregular dicks and gurgles. C. High pitched tinkling. D. Longed prolonged

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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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

During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Correct Answer is A

Explanation

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

Correct Answer is B

Explanation

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