A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?
Sounds are high-pitched
Can be a result of a paralytic ileus
Indicates decreased motility
Sounds are soft and at a rate of 1/min
The Correct Answer is A
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.
The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.
Correct Answer is A
Explanation
Cotton underwear is recommended for individuals with UTIs because it allows better air circulation and helps keep the genital area dry. This can prevent the growth of bacteria and reduce the risk of further infection.
Drink orange juice daily for 3 to 4 weeks: While hydration is important for overall health, there is no specific recommendation to drink orange juice or any specific juice for the treatment of a UTI. It is generally recommended to increase fluid intake, particularly water, to help flush out the bacteria from the urinary system.
Take the prescribed antibiotic until manifestations are gone: This instruction is correct. It is important for the client to take the full course of the prescribed antibiotic as directed by their healthcare provider, even if symptoms improve before completing the entire course. This helps ensure complete eradication of the bacteria and reduces the risk of antibiotic resistance.
Restrict fluid intake to 1 L per day: Adequate fluid intake is important for UTI management as it helps flush out bacteria from the urinary system. Restricting fluid intake to 1 liter per day is not recommended and may not provide sufficient hydration. It is generally advised to drink plenty of water and other fluids throughout the day.
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