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 C

Explanation

A. Wait for 4 hr before sending the specimen to the laboratory: Delaying the transport of stool specimens can affect test results by allowing bacterial growth or degradation of components. Specimens should be sent promptly or refrigerated if there is a delay.

B. Avoid collecting the specimen from areas of the stool that contain blood: If testing for occult blood or infection, areas with blood should be included because they provide important diagnostic information, so avoiding them is incorrect.

C. Transfer the specimen to a cup without it touching the outside of the container: Maintaining specimen integrity and preventing contamination is essential. The nurse should ensure the stool does not contact the outside of the container to avoid spreading pathogens and ensure accurate testing.

D. Collect at least 7.62 cm (3 in) of the client's stool: Collecting such a large amount is unnecessary; usually a smaller amount (about 1 inch or walnut size) is sufficient for testing, so this choice is incorrect.

A. The client is sedentary throughout most of the day. B. The client verbalizes regret about never marrying. C. The client has no living family. D. The client has poorly fitting dentures.

Correct Answer is D

Explanation

A. The client is sedentary throughout most of the day: While physical inactivity can lead to health issues such as muscle weakness and cardiovascular problems, it is not immediately life-threatening and can be addressed through lifestyle interventions.

B. The client verbalizes regret about never marrying: This reflects emotional distress or social isolation, which is important, but it does not pose an urgent physical health risk requiring immediate attention.

C. The client has no living family: Although lacking family support can affect long-term care planning and emotional well-being, it is not the most immediate threat to the client’s health in this context.

D. The client has poorly fitting dentures: This is the priority because it directly affects the client’s ability to eat, leading to potential malnutrition, weight loss, and decline in overall health—issues particularly dangerous for older adults.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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