NUR 309 Exam 3 study set (All Accurate 100%)

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? a. The spleen is normally felt upon routine palpation b. An enlarged spleen should not be palpated because it can rupture easily correct answers b. An enlarged spleen should not be palpated because it can rupture easily If an enlarged spleen is felt, then the nurse should refer the person but should not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation. Page: 549 A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is a. peritonitis b. diarrhea c. laxative use d. gastroenteritis correct answers a. peritonitis Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction. Page: 561 The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine areas of tenderness before using percussion and palpation." b. "It prevents distortion of bowel sounds that might occur after percussion and palpation." c. "It allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation." correct answers b. "It prevents distortion of bowel sounds that might occur after percussion and palpation Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. Pages: 538-539