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 A

Explanation

A. Paralytic ileus. A postoperative complication in which the intestines stop moving due to anesthesia or surgical trauma. Absence of bowel sounds, abdominal distention, and no flatus are key signs.

B. Incisional infection. An incisional infection would present with redness, warmth, drainage, and fever, but not absence of bowel sounds.

C. Fecal impaction. Fecal impaction causes stool retention, and the client might still pass small amounts of liquid stool, whereas paralytic ileus presents with no bowel movement at all.

D. Health care-associated Clostridium difficile. C. difficile infection presents with frequent watery diarrhea, not absent bowel sounds.

A. Stress incontinence B. Reflex incontinence C. Urge incontinence D. Overflow incontinence

Correct Answer is A

Explanation

A. Stress incontinence. Stress incontinence occurs when intra-abdominal pressure (e.g., sneezing, coughing, laughing) causes urine leakage due to weak pelvic floor muscles or urethral sphincter dysfunction.

B. Reflex incontinence. Reflex incontinence is involuntary urination without warning due to neurological dysfunction (e.g., spinal cord injury, multiple sclerosis), which is not the case here.

C. Urge incontinence. Urge incontinence is a sudden, intense need to urinate, often caused by overactive bladder syndrome or neurological disorders. It is not associated with sneezing.

D. Overflow incontinence. Overflow incontinence occurs when the bladder fails to empty completely, leading to dribbling of urine due to urinary retention (e.g., BPH, diabetic neuropathy).

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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