While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?
A minor variation.
Normal borborygmus sounds.
Possible renal artery stenosis.
Hyperactive bowel sounds.
The Correct Answer is C
Choice A rationale
A minor variation may refer to a benign finding or a slight deviation from the norm. However, a low-pitched blowing sound in the upper midline area would not typically be considered a minor variation and may warrant further investigation.
Choice B rationale
Borborygmi are normal bowel sounds characterized by gurgling, rumbling, or growling noises produced by the movement of gas and fluid in the intestines. However, a low-pitched blowing sound in the upper midline area would not typically be described as normal borborygmi.
Choice C rationale
A low-pitched blowing sound in the upper midline area could indicate a renal artery bruit, which is a sign of renal artery stenosis. Renal artery stenosis is a narrowing of the renal artery, often due to atherosclerosis, which can lead to decreased blood flow to the kidneys. A renal artery bruit may be auscultated over the renal arteries and is indicative of turbulent blood flow through the narrowed artery.
Choice D rationale
Hyperactive bowel sounds are typically characterized by loud, high-pitched gurgles heard throughout the abdomen. They are often associated with increased intestinal motility, such as in gastroenteritis or diarrhea, rather than a low-pitched blowing sound in the upper midline area.
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Correct Answer is D
Explanation
Choice A rationale
Demonstrating signs of early dementia involves more than just walking aimlessly and staring blankly. It includes memory loss, difficulty with complex tasks, and changes in personality or behavior.
Choice B rationale
Appearing confused and depressed is a subjective interpretation and does not accurately describe the observed behavior. Documentation should be objective and specific.
Choice C rationale
Ambulatory and disoriented to place is a partial description but does not capture the full extent of the observed behavior, including the blank expression.
Choice D rationale
Wandering behavior with flat affect accurately describes the observed behavior. It is specific and objective, noting both the physical action (wandering) and the emotional state (flat affect).
Correct Answer is C
Explanation
Choice A rationale
Hypotonic tone of the anal sphincter is an abnormal finding and may indicate neurological or muscular disorders affecting the sphincter control.
Choice B rationale
A dimpled area above the anus can be a sign of a congenital condition such as a pilonidal sinus or other abnormalities.
Choice C rationale
Increased pigmentation and coarse skin around the anus are normal findings and are due to the natural variation in skin texture and color in this area.
Choice D rationale
A flap of tissue at the sphincter, also known as a skin tag, can be a normal finding but may also indicate previous hemorrhoids or other conditions.