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. Tell the client to think about something else. B. Tell the client that everything will be okay. C. Ask the client to describe their support system. D. Ask the client why they're unable to cope.

Correct Answer is C

Explanation

A. Tell the client to think about something else: Redirecting the client's thoughts without addressing their emotional distress can be dismissive. It does not support emotional processing or help the nurse assess the client’s coping needs.

B. Tell the client that everything will be okay: Offering false reassurance minimizes the client’s feelings and may hinder open communication. It does not validate their experience or help develop coping strategies.

C. Ask the client to describe their support system: Exploring the client’s support system helps assess available emotional and practical resources. This information is essential in planning appropriate interventions and enhancing coping capacity.

D. Ask the client why they're unable to cope: "Why" questions can make clients feel defensive and judged. It is more therapeutic to use open-ended questions that invite sharing without implying blame.

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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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