A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Hypoactivity

Paralytic ileus

Borborygmi

Distention

Answer and Explanation

The Correct Answer is C

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

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Correct Answer is A

Explanation

A. Hyponatremia: Vomiting and diarrhea cause significant fluid loss, often leading to a decrease in sodium levels in the blood (hyponatremia) due to loss of electrolytes and dilution from fluid replacement or retained water.

B. Hyperkalemia: Vomiting and diarrhea usually cause potassium loss, resulting in hypokalemia rather than hyperkalemia, as potassium is lost through gastrointestinal fluids.

C. Hypocalcemia: Calcium levels are generally not directly affected by vomiting and diarrhea, so hypocalcemia is less likely in this scenario.

D. Hypermagnesemia: Magnesium is typically lost with gastrointestinal losses; therefore, hypermagnesemia is uncommon with vomiting and diarrhea.

A. Ensure the oxygen delivery system is at least 8 feet from any heat source. B. Store the oxygen cylinder wrench with the oxygen tank. C. Adjust the oxygen flow rate as needed to ease breathing. D. Take antibiotic medication with or without food. E. Take steroid medication in the morning. F. Decrease the steroid dose each day. G. Take antibiotics for 10 days.

Correct Answer is ["A","B","E","G"]

Explanation

A. Ensure the oxygen delivery system is at least 8 feet from any heat source: Oxygen is flammable, and this safety measure helps prevent fire hazards in the home environment.

B. Store the oxygen cylinder wrench with the oxygen tank: Keeping the wrench with the tank ensures quick and easy access in case the oxygen needs to be turned on or off during an emergency.

C. Adjust the oxygen flow rate as needed to ease breathing: Clients should never adjust oxygen flow independently; flow rate changes must be prescribed and monitored by the healthcare provider to prevent complications like oxygen toxicity or hypoventilation.

D. Take antibiotic medication with or without food: This varies by antibiotic. Cefazolin, for example, was given IV in the hospital, and the oral form prescribed for home use might require food to reduce GI side effects; instructions should be drug-specific.

E. Take steroid medication in the morning: Steroids mimic the body’s natural cortisol rhythm; taking them in the morning minimizes insomnia and other endocrine side effects.

F. Decrease the steroid dose each day: Steroid tapering must follow a specific provider-prescribed regimen. Improper tapering can lead to adrenal insufficiency or withdrawal symptoms.

G. Take antibiotics for 10 days: Completing the full antibiotic course, even if symptoms improve, helps prevent antibiotic resistance and ensures complete eradication of the infection.

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A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

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