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 B

Explanation

A. Speak with a loud voice while providing the information: Increasing the volume of speech is not effective for clients with expressive aphasia because their difficulty lies in producing language, not hearing. Speaking loudly may cause frustration or discomfort without improving communication.

B. Determine the client's ability to use a communication board: Assessing the client’s ability to use a communication board is an essential strategy to facilitate effective communication. Augmentative tools like communication boards can help them convey their needs and participate in teaching.

C. Provide the teaching without expecting the client to respond: Teaching without expecting any response can lead to missed opportunities for interaction and engagement. Encouraging some form of response, even nonverbal or through assistive devices, helps evaluate the client’s comprehension and maintains their involvement.

D. Avoid the use of facial gestures during the instructions: Facial gestures, body language, and visual cues play an important role in enhancing communication for clients with aphasia. Using expressive gestures should be encouraged to supplement verbal teaching and promote better comprehension.

A. Turn on loud music in client care areas. B. Assign different nurses to provide care for clients each day. C. Restrict the number of visitors for clients. D. Offer the clients many choices regarding care.

Correct Answer is C

Explanation

A. Turn on loud music in client care areas: Loud music can increase noise levels, which contributes to environmental stress and can disrupt clients’ rest and recovery. It is generally contraindicated in acute care settings where reducing stress and promoting healing are priorities.

B. Assign different nurses to provide care for clients each day: Frequent changes in caregivers can increase client anxiety and stress by reducing continuity of care and trust. Consistent assignments promote familiarity, comfort, and better communication between clients and caregivers.

C. Restrict the number of visitors for clients: Limiting visitors helps reduce noise and overcrowding, which are common environmental stressors in acute care units. This strategy supports a calmer environment conducive to client rest and recovery while maintaining essential social support.

D. Offer the clients many choices regarding care: While offering choices can promote autonomy, providing too many options may overwhelm clients, especially those who are ill or stressed. Simplifying decisions helps reduce cognitive overload and environmental stress.

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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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