The nurse is assessing a client who has a large bowel obstruction. Which late clinical finding would the nurse expect?

Loops of large bowel become visibly outlined through the abdominal wall

Intense thirst, parched tongue and dry mucous membranes

Vomiting of bile-stained gastric contents

High-pitched, frequent bowel sounds

Answer and Explanation

The Correct Answer is A

A. Loops of large bowel become visibly outlined through the abdominal wall is a typical late clinical finding of a large bowel obstruction. In fact, visible loops of bowel through the abdominal wall may be observed in cases of a severe bowel obstruction, but it is not typically considered a late finding.

B. Intense thirst, parched tongue, and dry mucous membranes suggest dehydration, which can occur as a result of vomiting, decreased fluid intake, or fluid loss due to the obstruction. However, dehydration may occur earlier in the course of a bowel obstruction and may not be considered a late finding.
C. Vomiting in large bowel obstruction is commonly of fecal contents.
D. High-pitched, frequent bowel sounds is not a typical late clinical finding of a large bowel obstruction. Instead, bowel sounds are usually diminished or absent in cases of bowel obstruction due to decreased peristalsis beyond the site of obstruction.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Chocolate can relax the lower esophageal sphincter (LES), allowing stomach acid to reflux into the esophagus and exacerbate symptoms. Therefore, it is advisable for clients with GERD to avoid chocolate.
B. Tomato-based products are acidic and can aggravate GERD symptoms. Tomatoes are naturally acidic, which can contribute to increased acidity in the stomach and exacerbate reflux symptoms.
C. Spicy and high-fat foods, such as hot and spicy pork rinds, can trigger GERD symptoms by increasing stomach acid production and relaxing the LES. Spicy foods can irritate the esophagus and exacerbate symptoms such as heartburn and reflux.
E. Oranges and other citrus fruits are acidic and can irritate the esophagus, exacerbating GERD symptoms. The acidity in oranges can increase stomach acid production and contribute to reflux.
D. Green beans are generally considered safe for individuals with GERD. They are low in fat and acidity, making them less likely to trigger reflux symptoms.

A. 1 B. 2 C. 3 D. 4

Correct Answer is B

Explanation

McBurney's point is located approximately one-third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus (navel), on the right side of the abdomen.

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The nurse is assessing a client who has a large bowel obstruction. Which late clinical finding would the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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