A client presents with a possible bowel obstruction, and the nurse completes a detailed abdominal assessment. Which of the following clinical manifestations are consistent with a large bowel obstruction? (Select all that apply).
Profuse vomiting with fecal odor
Epigastric abdominal distention
Intermittent abdominal cramping
Ribbon-like stools or diarrhea
Metabolic acidosis
Severe fluid and electrolyte imbalance
Correct Answer : A,B,C,D,E,F
Choice A reason:Profuse vomiting with a fecal odor can occur in large bowel obstructions due to the backward flow of bowel contents.
Choice B reason:Epigastric abdominal distention is a common finding in bowel obstructions due to the accumulation of gas and fluids.
Choice C reason:Intermittent abdominal cramping results from the bowel's attempt to push contents through the obstructed area.
Choice D reason:Ribbon-like stools or diarrhea may occur if there is a partial obstruction allowing some contents to pass.
Choice E reason:Metabolic acidosis can develop due to the accumulation of lactic acid from tissue hypoxia and decreased perfusion.
Choice F reason:Severe fluid and electrolyte imbalance can result from vomiting and the inability to absorb fluids and nutrients properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35"]
Explanation
- Step 1: Identify the total volume to be administered. The nurse is scheduled to administer 840 mL of enteral nutrition over a 24-hour period.
- Step 2: Identify the total time over which the volume is to be administered. The total time is 24 hours.
- Step 3: Calculate the rate at which the infusion pump should be set. We can do this by dividing the total volume by the total time:
- Rate = Total Volume ÷ Total Time.
- Rate = 840 mL ÷ 24 hours.
- Calculating the division gives us: Rate = 35 mL/hr.
set the infusion pump to deliver 35 mL/hr.
Correct Answer is C
Explanation
Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.
Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.
Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.
Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.
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