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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An assistive personnel raises all four side rails of a client's bed before leaving the room: Raising all four side rails can be considered a form of restraint and poses a safety risk, especially if the client attempts to climb over them. It can increase the risk of falls and injury, particularly in confused or restless clients.
B. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks: This is not a safety hazard; it's a fall prevention measure. These sensor mats are designed to alert staff when a client attempts to get up, helping prevent falls in at-risk individuals.
C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds:
A capillary refill of less than 2 seconds is within normal limits and indicates that circulation to the hands is intact. This suggests that the restraints are not too tight and do not currently pose a circulatory risk to the client.
D. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site: A mild buzzing or tingling sensation is an expected and normal effect of a TENS unit. It does not indicate a malfunction or a safety issue unless it becomes painful or the skin shows signs of irritation or burns.
Correct Answer is ["A","B","C","D"]
Explanation
A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.
B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.
C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.
D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth.This aligns with recommended guidelines.
E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.
F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.
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