The nurse is caring for an older adult in the medical-surgical unit:
84-year-old female was admitted to the medical-surgical unit with a three-day history of abdominal pain, distention, nausea, and persistent vomiting. She reports that she has not had a bowel movement in five days and has no appetite.
Which of the following findings are consistent with a small bowel obstruction: Select all that apply.
Right lower quadrant abdominal pain
Fever
Nausea and vomiting
Unable to pass stool
distended abdomen
Correct Answer : C,D,E
Choice A rationale: Small bowel obstructions typically present with diffuse, crampy abdominal pain rather than localized pain in the right lower quadrant.
Choice B rationale: While fever can be present in some cases, it's not a consistent finding with small bowel obstruction unless there's perforation.
Choice C rationale: Common symptoms of small bowel obstruction due to the buildup of contents proximal to the obstruction.
Choice D rationale: A key feature of small bowel obstruction due to the blockage preventing normal bowel movements.
Choice E rationale: Accumulation of gas and fluid above the obstruction causes abdominal distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.
Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of
lymphedema.
Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.
Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.
Correct Answer is A
Explanation
Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous
membranes of an infected person.
Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.
Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.
Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.
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