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    Hesi rn health assessment proctored exam

    When assessing a client’s abdomen, the nurse uses auscultation to assess for which possible finding?

    Explanation & Rationale

    Choice A rationale Guarding refers to voluntary or involuntary muscle contraction of the abdominal wall in response to pain or inflammation. This is assessed through palpation, where the nurse feels for muscle rigidity, not through auscultation, which involves listening to internal sounds. Choice B rationale Ascites, the accumulation of fluid in the peritoneal cavity, is primarily detected through inspection (distended abdomen), palpation (fluid wave, shifting dullness), and percussion. Auscultation is not the primary method for identifying the presence of free fluid in the abdominal cavity. Choice C rationale Striae, commonly known as stretch marks, are linear streaks or bands on the skin resulting from rapid stretching. These are visual findings, assessed through inspection of the skin surface, and cannot be detected by auscultation, which relies on sound perception. Choice D rationale Bruits are abnormal vascular sounds, often described as swishing or humming, produced by turbulent blood flow through a narrowed or dilated artery. Auscultation with a stethoscope is the appropriate technique to detect these sounds over abdominal arteries, indicating potential vascular abnormalities.

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