A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

High-pitched bowel sounds

Abdominal bruit

Bruising on the flank area

Coffee-ground emesis

Answer and Explanation

The Correct Answer is A

A) High-pitched bowel sounds: High-pitched bowel sounds, also known as "tinkling" sounds, are characteristic of mechanical bowel obstructions. These sounds are created by the intestines as they try to move contents past the obstruction, resulting in increased peristaltic activity. In the case of intussusception, where one segment of the intestine telescopes into another, the obstruction can cause these distinctive high-pitched sounds due to the narrowing of the bowel lumen.

B) Abdominal bruit: An abdominal bruit is a swishing sound heard over the abdomen, usually indicating turbulent blood flow through narrowed arteries. It is commonly associated with vascular conditions such as atherosclerosis or renal artery stenosis. It is not related to bowel obstruction, as bowel sounds in obstruction cases are generally due to changes in peristaltic activity rather than blood flow.

C) Bruising on the flank area: Bruising on the flank area, known as Grey Turner's sign, is typically seen in conditions involving retroperitoneal hemorrhage, such as severe pancreatitis or trauma. It is not a symptom of bowel obstruction. Bowel obstruction symptoms generally relate to the gastrointestinal tract and include abdominal pain, distension, and altered bowel sounds.

D) Coffee-ground emesis: Coffee-ground emesis is vomit that appears like coffee grounds, indicating the presence of partially digested blood. This is a sign of upper gastrointestinal bleeding, often due to peptic ulcers or gastritis. In mechanical bowel obstruction, vomiting is more likely to contain bile (bilious vomiting) and may occur if the obstruction is high in the small intestine. The appearance of coffee-ground emesis is not typical for bowel obstructions and indicates a different type of gastrointestinal issue.

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Correct Answer is D

Explanation

A) Drowsiness: While drowsiness can be a symptom of elevated magnesium levels, it is not the most critical finding to report immediately. Drowsiness can be observed with other conditions as well.

B) Diminished patellar reflexes: This can be indicative of hypermagnesemia, but it is a less immediate concern compared to other symptoms. Monitoring reflexes is important, but not the priority.

C) Generalized muscle weakness: Muscle weakness is a common symptom of elevated magnesium levels, but it is less urgent compared to cardiac issues. Although important, it does not pose an immediate risk like bradycardia.

D) Bradycardia: Elevated magnesium levels can cause serious cardiac complications, including bradycardia. This can be life-threatening and requires prompt attention to prevent severe outcomes, making it the priority to report to the provider.

A. Aspirin can be given to decrease the fever caused by varicella. B. Maintaining a warm environment decreases the eruption of lesions. C. Varicella has an incubation period of 1 to 3 days. D. An antihistamine can be administered to decrease pruritus.

Correct Answer is D

Explanation

A) Aspirin can be given to decrease the fever caused by varicella: Aspirin should not be used in children with varicella (chickenpox) due to the risk of Reye’s syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen is recommended for fever management in these cases.

B) Maintaining a warm environment decreases the eruption of lesions: Maintaining a warm environment does not affect the eruption of varicella lesions and could potentially exacerbate discomfort. A cool environment and loose, comfortable clothing are preferred to help alleviate itching and discomfort.

C) Varicella has an incubation period of 1 to 3 days: The incubation period for varicella is typically 10 to 21 days after exposure. The shorter period of 1 to 3 days is not accurate for varicella and does not reflect the standard incubation period of this disease.

D) An antihistamine can be administered to decrease pruritus: Antihistamines are effective in managing itching (pruritus) associated with varicella lesions. They can help provide relief from the discomfort caused by the rash, making this an appropriate intervention.

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A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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