A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include?

Provide bulk-forming agent.

Elevate the head of the bed.

Measure abdominal girth daily.

Monitor intake and output every 8 hr.

Answer and Explanation

The Correct Answer is B

Choice A: Provide bulk-forming agent. This is incorrect because bulk-forming agents are used to treat constipation, not bowel obstruction. They can worsen the obstruction by increasing the stool volume and pressure in the bowel.

Choice B: Elevate the head of the bed. Elevating the head of the bed is an important intervention for clients with a small bowel obstruction. It can help reduce abdominal pressure, promote comfort, and facilitate better respiratory function, especially if the client is experiencing any associated nausea or vomiting. This position can also aid in the proper positioning of the intestines, potentially helping with any non-complicated obstructions.

Choice D: Monitor intake and output every 8 hr. This is incorrect because monitoring intake and output is not enough to assess the ﬂuid and electrolyte balance of a client with a bowel obstruction. The nurse should monitor intake and output more frequently, such as every 4 hr or every shift, and report any signs of dehydration or imbalance.

Choice C: Measure abdominal girth daily. While this is an important assessment for monitoring the status of the obstruction, the immediate intervention of elevating the head of the bed can provide immediate comfort and support during the acute phase of the obstruction.

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Correct Answer is B

Explanation

Choice A: Blurred vision is not a typical finding of hypothyroidism. It can be caused by other conditions, such as diabetes, glaucoma, or eye strain.

Choice B: Bradycardia is a slow heart rate, usually below 60 beats per minute. This is a common finding of hypothyroidism, as the thyroid hormone regulates the metabolic rate and aﬀects the cardiovascular system. Low levels of thyroid hormone can cause the heart to beat slower and weaker.

Choice C: Insomnia is difficulty falling or staying asleep. This is not a common finding of hypothyroidism, as low thyroid hormone levels can cause fatigue, lethargy, and excessive sleepiness.

Choice D: Moist skin is not a common finding of hypothyroidism, as low thyroid hormone levels can cause dry skin, hair loss, and britle nails. Moist skin can be a sign of hyperthyroidism, which is the opposite condition of hypothyroidism.

A. “This test detects antithyroid antibodies in your blood.” B. “This test measures the amount of thyroid hormone that ataches to a protein in your blood.” C. “This test determines whether your thyroid gland is overactive, appropriately active, or underactive.” D. “This test measures the absorption of iodine and how it relates to the thyroid gland.”

Correct Answer is C

Explanation

Choice A reason: This test does not detect antithyroid antibodies in your blood. Antithyroid antibodies are proteins that atack the thyroid gland and can cause autoimmune thyroid diseases, such as Hashimoto’s thyroiditis or Graves’ disease. To detect antithyroid antibodies, you need a diﬀerent blood test called the thyroid peroxidase (TPO) antibody test.

Choice B reason: This test does not measure the amount of thyroid hormone that ataches to a protein in your blood. Thyroid hormone can exist in two forms in the blood: free or bound. Free thyroid hormone is not atached to any protein and can enter the cells and tissues where it is needed. Bound thyroid hormone is atached to a protein called thyroxine-binding globulin (TBG) and cannot enter the cells and tissues. To measure the amount of thyroid hormone that ataches to TBG, you need a diﬀerent blood test called the total thyroxine (T4) test.

Choice C reason: This test determines whether your thyroid gland is overactive, appropriately active, or underactive. TSH is a hormone produced by the pituitary gland that stimulates the thyroid gland to make and release thyroid hormones, such as thyroxine (T4) and triiodothyronine (T3). These hormones regulate many body functions, such as metabolism, growth, and development. The TSH test measures the amount of TSH in the blood and reﬂects how well the thyroid gland is working. If the TSH level is high, it means that the thyroid gland is underactive (hypothyroidism) and not making enough thyroid hormones. If the TSH level is low, it means that the thyroid gland is overactive (hyperthyroidism) and making too much thyroid hormones.

Choice D reason: This test does not measure the absorption of iodine and how it relates to the thyroid gland. Iodine is a mineral that is essential for the production of thyroid hormones. The thyroid gland absorbs iodine from the food and water we consume and uses it to make T4 and T3. To measure the absorption of iodine by the thyroid gland, you need a diﬀerent test called the radioactive iodine uptake (RAIU) test.

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A nurse is contributing to the plan of care of a client who has a small bowel obstruction. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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