When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Absent

Blowing sound due to restriction.

A continuous medium pitched sound.

High pitched, tinkling, rushing or growling.

Answer and Explanation

The Correct Answer is D

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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Correct Answer is D

Explanation

A. Nausea – Not a primary manifestation of hypoxia. Hypoxia primarily affects oxygen delivery to tissues, leading to respiratory and neurological changes.

B. Dysphagia – Difficulty swallowing is not a common sign of hypoxia. It is more often associated with neurological conditions or structural abnormalities.

C. Warm, dry skin – Hypoxia typically causes cool, clammy skin due to vasoconstriction and poor oxygenation, not warm, dry skin.

D. Cyanosis – Correct. Cyanosis (bluish discoloration of the skin, lips, or nail beds) occurs due to inadequate oxygenation of the blood, making it a key sign of hypoxia.

A. The client takes a 20-min nap each afternoon. B. The client has gained 4.5 kg (10 lb) in the past month. C. The client takes a walk for 1 hr each day. D. The client is taking a poetry class.

Correct Answer is B

Explanation

A. The client takes a 20-min nap each afternoon. Taking a short nap is a healthy coping mechanism and does not indicate ineffective coping.

B. The client has gained 4.5 kg (10 lb) in the past month. Sudden weight gain can indicate emotional eating or stress-related metabolic changes, which are signs of ineffective coping.

C. The client takes a walk for 1 hr each day. Walking is a positive coping strategy that helps manage stress.

D. The client is taking a poetry class. Engaging in creative activities is a healthy coping mechanism that can reduce stress.

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When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?

Correct Answer is B

Explanation

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

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A nurse is checking a school-age child for pediculosis capitis (head lice). Which of the following findings is a definitive indication of this condition?

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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?