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
The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.
While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.
Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.
Correct Answer is C
Explanation
a.Adequate fluid intake is important while taking ciprofloxacin to prevent dehydration, especially if diarrhea occurs.
b. Ciprofloxacin can disrupt the normal balance of bacteria in the gastrointestinal tract, potentially leading to diarrhea. Informing the client about this possible side effect allows them to be prepared and take appropriate measures, such as maintaining hydration and notifying their healthcare provider if diarrhea becomes severe or persistent. However, warning about sunburnis crucial as it addresses a specific side effect (photosensitivity) that clients may not be aware of, and it provides actionable advice to mitigate the risk (use of sunscreen and protective clothing).
c.Ciprofloxacin, like other fluoroquinolone antibiotics, can increase sensitivity to sunlight (photosensitivity). Clients should be advised to use sunscreen, wear protective clothing, and avoid prolonged sun exposure while taking this medication.
d.Ciprofloxacin should not be taken with antacids, calcium supplements, or dairy products because they can interfere with the absorption of the medication. It's best to take ciprofloxacin either 2 hours before or 6 hours after taking antacids or products containing calcium, magnesium, aluminum, iron, or zinc.
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