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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Syringe: A syringe is essential for irrigating a stage 4 pressure injury to cleanse the wound thoroughly without causing trauma to the tissue. Proper irrigation helps remove debris and bacteria, promoting healing. A syringe allows controlled, gentle flushing of the wound bed, which is important in managing deep, complex wounds like stage 4 pressure injuries.

B. Tongue depressor: A tongue depressor is generally used to examine the throat and oral cavity and is not suitable for wound care. It lacks the precision and safety needed for wound cleaning or dressing application, especially for deep pressure ulcers.

C. Adhesive tape: Adhesive tape is used to secure dressings but is not a primary supply for wound care itself. In managing a stage 4 pressure injury, the priority is proper wound cleaning and dressing materials rather than just securing them, so adhesive tape is secondary.

D. Cotton-tipped applicator: Cotton-tipped applicators are commonly avoided in wound care because they can leave fibers in the wound bed and potentially cause trauma or infection. They are not recommended for cleaning or applying medication to deep pressure ulcers, where more sterile, gentle methods are needed.

A. Testicular examination B. Colonoscopy C. Clinical breast examination D. Fasting blood glucose

Correct Answer is B

Explanation

A. Testicular examination: Testicular cancer screening is typically encouraged from adolescence to around age 35, as it is more common in younger men. Routine testicular exams are not specifically recommended starting at age 50.

B. Colonoscopy: Colorectal cancer screening, such as colonoscopy, should begin at age 45 or 50 for individuals at average risk. It is a key preventive measure for detecting colorectal cancer in its early stages.

C. Clinical breast examination: Clinical breast exams may be done earlier, typically starting in the 20s or 30s, depending on risk factors. They are not newly initiated at age 50.

D. Fasting blood glucose: Screening for diabetes may begin as early as age 35 in adults with risk factors. It is important but not specifically recommended as a new screening starting at age 50.

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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

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