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 A
Explanation
A) Stiff neck and shoulder pain: This symptom is very common in clients with a herniated cervical disc. The herniation can lead to irritation or compression of nearby nerves, resulting in localized pain in the neck and shoulder region. Clients often report this discomfort as one of their primary concerns.
B) Cauda equina syndrome: This serious condition arises from compression of the cauda equina, which occurs in the lower lumbar region of the spine, not the cervical area. Therefore, it is not a typical symptom of a cervical disc herniation.
C) Changes in knee and ankle reflexes: These changes are more associated with lumbar spine issues. While cervical disc problems can affect reflexes, they typically do not present as changes in lower limb reflexes, which are primarily linked to lower back conditions.
D) Sciatica: This term usually refers to pain that radiates down the leg due to compression of the sciatic nerve, often associated with lumbar disc herniation. It is not a common symptom of cervical disc herniation, which affects the neck and upper extremities.
Correct Answer is ["B","C","D","E"]
Explanation
A) Range of motion: While assessing range of motion can provide information about joint function, it is not a specific component of a peripheral vascular assessment. This assessment primarily focuses on circulation and vascular integrity rather than mobility.
B) Color: Assessing the color of the upper extremities is essential in a peripheral vascular assessment. Changes in color can indicate issues such as poor circulation, hypoxia, or vascular disease, making it a critical observation.
C) Fine motor assessment by having the client touch each finger to thumb: This assessment evaluates both coordination and dexterity, which can indicate adequate blood flow to the fingers and upper extremities. It helps to assess the functional capacity of the hands in relation to vascular health.
D) Pain assessment: Evaluating for pain in the upper extremities is important, as pain can be a sign of vascular problems, including conditions like peripheral artery disease. It provides insight into the presence of ischemia or other vascular issues.
E) Pulses intact: Assessing the pulses in the upper extremities is a key component of a peripheral vascular assessment. Palpating the radial and brachial pulses helps determine blood flow and vascular function in the arms.