When assessing the abdomen, the nurse would expect to auscultate which sounds?
Friction rubs
Crepitus
Bruits
High pitched gurgling
The Correct Answer is D
A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.
B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.
C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.
D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.
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Correct Answer is D
Explanation
A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.
B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.
C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.
D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.
Correct Answer is C
Explanation
A) Notify the healthcare provider that the client is exaggerating their pain: It is inappropriate for the nurse to assume that the client is exaggerating their pain based solely on their demeanor. Pain perception is subjective and can vary greatly among individuals, especially in conditions like sickle cell anemia.
B) Wait 30 minutes and see if the client is still requesting pain medication: Delaying pain relief can lead to unnecessary suffering. Given that the client rates their pain as a 7 out of 10, which indicates significant discomfort, it is essential to address their pain promptly rather than postponing treatment.
C) Administer the pain medication as prescribed: This is the most appropriate action. Clients with sickle cell anemia often experience severe pain crises, and effective pain management is crucial. Administering the medication as prescribed supports the client's comfort and well-being.
D) Administer half of the ordered dose of pain medication: Modifying the dosage without a provider's order is not appropriate. If the full prescribed dose is warranted based on the pain level, the nurse should administer it as indicated to ensure effective pain management.