When assessing the abdomen, the nurse would expect to auscultate which sounds?
A.
High-pitched gurgling
B.
Bruits
C.
Friction rubs.
D.
Low-pitched sonorous sounds
The Correct Answer and Explanation is:
Correct Answer: A. High-pitched gurgling
Explanation:
When assessing the abdomen, the nurse should expect to auscultate high-pitched gurgling sounds, which are the normal bowel sounds. These sounds are created by the movement of gas and fluid through the intestines as part of the digestive process.
Understanding Normal Bowel Sounds:
- Bowel sounds are the noises produced by the intestines during peristalsis, which is the movement of contents through the gastrointestinal tract. These sounds are typically high-pitched and gurgling because they result from the movement of air and fluid through the small and large intestines.
- The normal frequency of bowel sounds ranges from 5 to 30 times per minute. They are usually irregular, occurring at various intervals.
Abnormal Sounds and Their Significance:
- Bruits (Option B) are not normal bowel sounds. They are abnormal sounds, typically low-pitched and blowing, caused by turbulent blood flow within an artery. If a nurse auscultates a bruit in the abdomen, it could indicate the presence of an arterial obstruction, such as an abdominal aortic aneurysm or renal artery stenosis. This is a serious finding that requires further investigation.
- Friction rubs (Option C) are also abnormal and not expected during a normal abdominal assessment. These sounds occur when there is inflammation of the peritoneal surface, such as with peritonitis or a liver tumor. Friction rubs are rare and are indicative of pathology, requiring further medical evaluation.
- Low-pitched sonorous sounds (Option D), also known as borborygmi, can occur normally but are usually associated with hyperactive bowel activity. These sounds might be heard in conditions like gastroenteritis or as part of a bowel obstruction. However, they are not the typical sounds expected during a normal abdominal assessment.
Clinical Implications:
- Auscultating normal bowel sounds confirms that the digestive system is functioning properly. A lack of bowel sounds (known as absent bowel sounds) could indicate a medical emergency, such as a bowel obstruction or paralytic ileus, and requires immediate attention.
- Conversely, hyperactive or hypoactive bowel sounds might suggest different conditions. Hyperactive sounds could indicate diarrhea, while hypoactive sounds might suggest constipation or post-surgical recovery.
Conclusion:
In summary, the correct and expected sounds during abdominal auscultation are high-pitched gurgling sounds. These sounds represent normal peristalsis and the healthy movement of air and fluid through the intestines. Abnormal sounds like bruits, friction rubs, or very low-pitched sonorous sounds could indicate underlying pathologies and warrant further investigation. Understanding these sounds allows the nurse to assess the function of the gastrointestinal system accurately and identify potential abnormalities.