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 D
Explanation
Choice A Reason:
Weight loss is inappropriate. Weight loss can occur in individuals with COPD, particularly in advanced stages of the disease. Factors contributing to weight loss may include decreased appetite, increased energy expenditure due to labored breathing, and muscle wasting.
Choice B Reason:
Poor nutrition is inappropriate. Poor nutrition is a significant risk factor in COPD. Individuals with COPD may experience difficulties with eating due to dyspnea, fatigue, and reduced appetite. Malnutrition can lead to muscle weakness, decreased immune function, and worsened respiratory status.
Choice C Reason:
Muscle dysfunction is inappropriate: Muscle dysfunction, particularly skeletal muscle dysfunction, is common in COPD. Reduced physical activity, systemic inflammation, oxidative stress, and metabolic abnormalities contribute to muscle wasting and weakness in individuals with COPD.
Choice D Reason
.Increased risk for pneumonia is incorrect. Individuals with COPD are at an increased risk for respiratory infections, including pneumonia. COPD-related factors such as impaired mucociliary clearance, airway inflammation, and reduced lung function predispose patients to respiratory infections.
Correct Answer is B
Explanation
Choice A Reason:
A client with a decreased potassium level is incorrect. Hypokalemia (decreased potassium level) can cause various neurological symptoms, but it doesn't directly lead to osmotic cerebral edema.
Choice B Reason:
When plasma glucose levels are rapidly lowered, an osmotic gradient develops between the brain and plasma, which can lead to cerebral edema.Brain cells pull water from the plasma, resulting in widespread edema.
Choice C Reason:
While HbA1c is an important marker of diabetes control and may indicate poor long-term management, it does not directly relate to the acute metabolic derangements (e.g., rapid osmotic shifts, severity of acidosis) that predispose to cerebral edema in DKA.
Choice D Reason:
A client with an increased creatinine level is incorrect. Elevated creatinine levels typically indicate kidney dysfunction or dehydration, but they don't directly cause osmotic cerebral edema.
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