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During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
- A. Constipation
- B. Air-filled areas
- C. Presence of a tumor
- D. Presence of dense organs
Correct Answer: B
Rationale: A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
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Which technique of assessment will the healthcare provider use to determine the presence of crepitus, swelling, and pulsations?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: A
Rationale: Palpation involves using the sense of touch to assess various characteristics such as texture, temperature, moisture, organ location and size, as well as detecting swelling, pulsations, vibrations, rigidity, crepitus, lumps, masses, and tenderness or pain. In this scenario, the healthcare provider would utilize palpation to physically feel for crepitus, swelling, and pulsations. Inspection primarily relies on visual assessment, percussion involves assessing through palpable vibrations and audible sounds, and auscultation uses the sense of hearing. Therefore, the correct answer is palpation for assessing the presence of crepitus, swelling, and pulsations.
The healthcare provider is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness?
- A. Holistic
- B. Biomedical
- C. Naturalistic
- D. Magicoreligious
Correct Answer: B
Rationale: The correct answer is B: Biomedical. Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic or holistic perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health. Therefore, options A, C, and D are incorrect as they do not align with the germ theory explanation provided in the question.
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
- A. Electrocardiogram
- B. Bell of the stethoscope
- C. Diaphragm of the stethoscope
- D. Palpation with the nurse's palm of the hand
Correct Answer: B
Rationale: The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.
In which situation would the nurse use bimanual palpation technique?
- A. Palpating the thorax of an infant
- B. Palpating the kidneys and uterus
- C. Assessing pulsations and vibrations
- D. Assessing the presence of tenderness and pain
Correct Answer: B
Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.
The healthcare professional is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
- A. Used to listen for high-pitched sounds
- B. Used to listen for low-pitched sounds
- C. Should be firmly held against the person's skin to block out low-pitched sounds
- D. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs
Correct Answer: A
Rationale: The diaphragm of the stethoscope is designed for listening to high-pitched sounds like breath, bowel, and normal heart sounds. It should be firmly held against the person's skin to ensure optimal sound transmission, leaving a ring after use. On the other hand, the bell of the stethoscope is ideal for detecting soft, low-pitched sounds such as extra heart sounds or murmurs. Therefore, the diaphragm is not used to block out low-pitched sounds but rather to enhance the detection of high-frequency sounds.