The physician comments that the client has abdominal borborygmi. The nurse recognizes that which of the following is the best description of borborygmi?
A peritoneal friction rub
Loud continual humming bowel sounds
Hypoactive bowel sounds
Loud gurgling bowel sounds
The Correct Answer is D
Choice A rationale: A peritoneal friction rub is a grating sound caused by the movement of inflamed peritoneal surfaces and is not associated with bowel sounds.
Choice B rationale: Loud continual humming bowel sounds do not accurately describe borborygmi and are not a common term used to describe bowel sounds.
Choice C rationale: Hypoactive bowel sounds indicate decreased bowel motility and are not associated with borborygmi.
Choice D rationale: Borborygmi refers to loud, gurgling bowel sounds that are audible without the use of a stethoscope. It is a normal sound associated with the movement of gas and fluid through the intestines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Estimating the degree of flexion and extension in each joint is more related to joint range of motion, not muscle strength.
Choice B rationale: Measuring the degree of force that it takes to overcome joint flexion or extension is not a standard method for assessing muscle strength.
Choice C rationale: To assess muscle strength, the nurse should apply an opposing force when the individual puts a joint in flexion or extension. This helps evaluate the strength of the muscles and their ability to move the joint against resistance.
Choice D rationale: Observing muscles for the degree of contraction when lifting a heavy object may provide information on muscle function but is not a specific muscle strength assessment.
Correct Answer is D
Explanation
Choice A rationale: CN X (vagus nerve) and CN VII (facial nerve) are separate cranial nerves, and the described findings are more indicative of dysfunction in the motor component of CN VII.
Choice B rationale: CN XI (accessory nerve) is primarily involved in motor function related to the sternocleidomastoid and trapezius muscles. It is not likely to cause the described facial asymmetry.
Choice C rationale: CN IV (trochlear nerve) is responsible for eye movement and would not be directly related to the described facial findings.
Choice D rationale: The described findings, such as asymmetry when smiling or frowning, uneven lifting of the eyebrows, and escape of air when pressing against a puffed cheek, indicate dysfunction of the motor component of cranial nerve VII (facial nerve).
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