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 {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Choice A rationale: A three-point gait is used when one leg is weaker or injured and cannot bear weight. The client should place the crutches about 12 inches in front of the feet and lean forward on the crutches. Then, the client should lift the injured leg and
swing the body forward between the crutches, landing on the uninjured leg. The client should not put any weight on the injured ankle, as ordered by the physician.
Choice B rationale: A four-point gait is used when both legs can bear some weight, but one is weaker than the other.
Choice C rationale: A swing-through gait is used when both legs can bear weight, but need assistance with balance and coordination.
Choice D rationale: A two-point gait is used when both legs have equal strength and can bear full weight.
Correct Answer is C
Explanation
Choice A rationale: This statement is correct; it's important to include the final voided urine in the collection.
Choice B rationale: Proper storage at a cool temperature helps maintain the integrity of the collected urine.
Choice C rationale: Avoiding protein intake during the collection can significantly alter the results of the creatinine clearance test. Eating a regular diet is important to maintain accurate test results.
Choice D rationale: Discarding the first void and starting the collection afterward is a common practice in 24-hour urine collections to ensure a complete sample.
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