A nurse is caring for a client who has a spinal cord injury and has absent bowel sounds in the lower abdominal quadrants. Which of the following actions should the nurse perform?
Place the client on clear liquids.
Perform a hemoccult blood test.
Insert a nasogastric tube.
Force the intake of fluids.
The Correct Answer is C
Choice A Reason:
Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.
Choice B Reason:
Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.
Choice C Reason:
Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.
Choice D Reason:
Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A Reason:
Bladder spasms are not commonly reported as adverse effects of methylprednisolone. However, bladder dysfunction can occur in individuals with multiple sclerosis due to the disease process itself, but it is not specifically related to corticosteroid therapy.
Choice B Reason:
Hypotension is not a common adverse effect of methylprednisolone. In fact, corticosteroids can often lead to fluid retention and sodium retention, which can contribute to hypertension rather than hypotension.
Choice C Reason:
Delayed wound healing is correct. Corticosteroids can impair the body's ability to heal wounds by suppressing the inflammatory response and collagen synthesis. Therefore, clients receiving methylprednisolone may experience delayed wound healing, which can be problematic, especially in individuals with pre-existing wounds or undergoing surgical procedures.
Choice D Reason:
Hirsutism (excessive hair growth, especially in women) can occur with long-term corticosteroid use due to the effect of steroids on hair follicles. It is a possible adverse effect of methylprednisolone.
Choice E Reason:
Hyperglycemia is correct. Corticosteroids can increase blood glucose levels by promoting gluconeogenesis, reducing glucose uptake by tissues, and inducing insulin resistance. Clients receiving methylprednisolone may develop hyperglycemia, which can be particularly concerning for individuals with diabetes or those at risk of developing diabetes.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Reason:
Chronic cough is correct. Persistent cough is a common symptom of COPD, often occurring due to irritation and inflammation in the airways.
Choice B Reason:
Sputum production is correct. COPD patients frequently experience increased mucus production, leading to coughing up phlegm or sputum, especially in the morning.
Choice C Reason:
Dyspnea is correct. Shortness of breath or dyspnea is a hallmark symptom of COPD, particularly during physical activity or exertion, and it tends to worsen as the disease progresses.
Choice D Reason:
Wheezing occurs due to narrowed airways and increased airway resistance. It is more noticeable during expiration but can also be present during inspiration in severe cases.
Choice E Reason:
Chest tightness is incorrect. While chest tightness can occur in COPD, it is typically more associated with asthma. However, some individuals with COPD may experience chest tightness, especially during exacerbations or when airflow is significantly limited.
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