A 68-year-old female client is being seen for follow-up wound care on her right lower leg. During her visit, the client states she hasn't had a bowel movement since her last visit a week ago. The client states she hasn't had much of an appetite in the past few days and says, "l figure I don't have anything in there to come out." The nurse auscultates the client's abdomen and hears hyperactive high-pitched bowel sounds in the upper left quadrant and hypoactive bowel sounds in the lower left quadrant. The nurse collaborates with the primary health care provider and the client is directly admitted to the hospital for possible intestinal obstruction. Before going to the hospital, the client asks the nurse what to expect. Which of these statements by the nurse (is) most likely accurate?
Select all that apply.
You should drink lots of water to help move the stool out of your body.
Surgery will be necessary to remove any Obstruction.
A nasogastric (NG) tube will be placed to relieve distention.
An abdominal CT will determine if you have an intestinal obstruction.
Correct Answer : C,D
Option A is not the best advice because drinking lots of water alone may not be enough to relieve constipation, especially if there is an obstruction.
Option B is also not accurate because not all intestinal obstructions require surgery, and the treatment approach will depend on the cause and severity of the obstruction.
Option C is accurate because a nasogastric tube can help relieve any distention caused by the obstruction by removing any gas or fluids that may have accumulated in the stomach and small intestine.
Option D is also accurate because an abdominal CT is one of the diagnostic tests that can help confirm the presence of intestinal obstruction and provide information about the location and cause of the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diabetes insipidus is a condition in which the body is unable to properly regulate fluid balance, leading to excessive urination (polyuria) and thirst. Therefore, the nurse should anticipate the clinical manifestation of polyuria in a patient admitted to the hospital with diabetes insipidus. The patient may excrete large amounts of dilute urine, which can lead to dehydration if adequate fluid replacement is not provided. The other options listed (fluid volume overload, decreased gas exchange, and generalized edema) are not typically associated with diabetes insipidus, as this condition is characterized by a deficiency of antidiuretic hormone (ADH) rather than an excess of fluid.
Correct Answer is A
Explanation
The most helpful finding by the nurse in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (pyelonephritis) would be
**costovertebral tenderness**⁴. This is because costovertebral tenderness is a common symptom of pyelonephritis⁵. Pyelonephritis is an infection of the upper urinary tract that can cause fever, chills, flank pain, nausea, vomiting, and costovertebral tenderness⁵. Foul-smelling urine and bladder distention are not specific symptoms of pyelonephritis⁵. Suprapubic discomfort can be a symptom of lower urinary tract infection⁵.
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