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) Splint and immobilize the extremity: While immobilizing the injured extremity is important to prevent further injury, it should follow an initial assessment of blood flow and nerve function to ensure there are no vascular or neurological compromises.
B) Apply an ice pack to the ankle: Applying ice can help reduce swelling and alleviate pain. However, it is essential first to assess the circulation to the limb to ensure that applying ice will not worsen any underlying issues.
C) Encourage weight bearing and ambulation: Encouraging weight bearing on a potentially injured ankle can lead to further damage and is not appropriate. The priority is to assess the injury and understand its severity.
D) Assess pulse, color, temperature, and capillary refill: This step is crucial as it evaluates the vascular status of the limb. Assessing these factors helps identify any potential complications, such as compartment syndrome or inadequate blood flow, and guides further management of the injury.
Correct Answer is A
Explanation
A) Obtain a height and weight and calculate a body mass index (BMI): Calculating BMI provides a valuable assessment of a patient’s body composition and overall health related to dietary habits. BMI is a widely used indicator that helps categorize individuals into underweight, normal weight, overweight, and obese categories. Understanding where a patient falls within these categories can highlight the potential impact of dietary habits on health and guide further dietary interventions or education.
B) Review all medications the patient is taking: While reviewing medications is important, it primarily focuses on pharmacological management rather than directly assessing dietary habits. Some medications may have dietary restrictions or require specific nutrient intake, but this does not provide a comprehensive view of the patient's overall dietary habits and their effects on health.
C) Ask about how much food is eaten at an average meal: While inquiring about portion sizes is relevant, it does not give a full picture of dietary habits, including food variety, nutrient quality, and frequency of meals or snacks. A single question about average meal size may overlook other critical aspects of the patient’s eating patterns and nutritional intake.
D) Assess for the presence of any chronic disease processes: Evaluating chronic diseases is crucial for understanding health implications, but it does not directly assess dietary habits. Chronic conditions can be influenced by diet, but the assessment of dietary habits requires a more direct inquiry into nutritional intake and lifestyle choices rather than focusing solely on disease presence.