20 Questions
What is the correct sequence for evaluating the aortic region of the abdomen and the lower region of the abdomen?
Evaluate the aortic region first, then the lower region
Why should the nurse use the bell, not the diaphragm, of the stethoscope when assessing vascular sounds in the abdomen?
The bell provides better amplification of high-pitched sounds
Which of the following accurately describes Borborygmi?
It is a normal bowel sound caused by peristalsis
When assessing for vascular sounds in the abdomen, why should the nurse only expose the region being assessed?
To maintain patient privacy and dignity
What assessment finding in a client with gastroenteritis should prompt the nurse to contact the health care provider?
Distended abdomen with visible peristalsis
Which finding would be considered normal in a client with gastroenteritis?
Borborygmi in all four quadrants
In a client with gastroenteritis, what finding would suggest a need for immediate medical attention?
Visible abdominal distention and tenderness
During assessment of a client with gastroenteritis, which finding could be mistaken for a normal variant?
Diffuse abdominal tenderness and cramping
Which assessment finding in a client with gastroenteritis would require urgent follow-up by the health care provider?
Loud, gurgling sounds throughout the abdomen
What is the most appropriate action for the nurse to take next for the client presenting with severe right lower quadrant pain and a fever of 38.6°C?
Prepare the client for immediate surgery
Which vital sign finding is most indicative of a potential acute surgical emergency in this client?
Fever of 38.6°C (101.5°F)
What is the rationale for keeping the client NPO in this situation?
To prepare for possible surgery
Why is cleansing the abdomen with chlorhexidine important for this client?
To prevent surgical site infection
Which additional assessment finding would further support the nurse's suspicion of acute appendicitis in this client?
Rebound tenderness in the right lower quadrant
What type of bowel sounds would the nurse expect to document in a healthy client during an abdominal assessment?
Soft, tinkling sounds every 5 to 34 seconds
Which term would be used to describe bowel sounds that are gurgling, continuous, and louder than normal?
Hyperactive
What is the correct interpretation of blowing, swooshing sounds at the ileac region during an abdominal assessment?
Bruit sounds
When would bowel sounds be considered absent during an abdominal assessment?
After auscultating for 2 minutes with no sounds heard
If a client with asthmatic bronchitis had bruit sounds in the ileac region, what would be the likely interpretation of this finding?
Abnormal finding, possibly indicating a vascular issue
What distinguishes normoactive bowel sounds from hyperactive bowel sounds?
Occurring every 5 to 34 seconds vs. gurgling, continuous, and louder
Identify variables that influence bowel elimination. Assist with stool collection for laboratory analysis Discuss the nursing care of a patient undergoing direct and indirect visualization studies of the gastrointestinal tract Identify appropriate nursing interventions to promote regular bowel habits and to ease defecation Discuss the physiologic changes affecting the bowel elimination process of the older adult
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