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
a. Sounds are high-pitched.
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 in 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 D
Explanation
A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.
B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.
C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.
D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.
Correct Answer is D
Explanation
The correct action to take in this situation is to place a pillow or cushion under the child's head.
This will help protect the child from injuring their head during the seizure.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
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