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. "My doctor will choose which medical procedures I will have." A living will allows the client to specify their own wishes regarding medical treatment, rather than leaving decisions solely to the doctor. It is a legal document that guides providers based on the client’s preferences.

B. "I can revise my living will if I change my mind." Clients have the right to update or revoke their living will at any time, reflecting changes in their preferences or health status. This flexibility is an important aspect of advance directives and indicates understanding.

C. "My family can change the decisions in my living will." The family cannot override the client’s living will unless legally appointed as a healthcare proxy. The living will represents the client’s autonomous decisions and must be honored by healthcare providers.

D. "I need an attorney to write my living will." While legal advice can be helpful, clients do not need an attorney to create a living will. Many states provide standardized forms that individuals can complete without legal assistance.

A. "We can discuss this after completing the admission process." B. "Your partner is in the denial stage of grief." C. "You should discuss this problem with your family members." D. "Your partner is experiencing an expected response to the dying process."

Correct Answer is D

Explanation

A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.

B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.

C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.

D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.

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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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