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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Ask the client to push her legs and feet against the nurse's palms. This action directly assesses the client’s muscle strength and ability to bear weight, which is essential before ambulation.

B. Check the client's pedal pulses and feet for edema. While circulatory assessment is important, it does not assess muscle strength, which is needed for safe ambulation.

C. Ask the client if she has been out of bed today. The client’s response does not objectively measure strength or readiness for ambulation.

D. Ask the client how strong she feels today. A client’s perception of strength may not be accurate and is not an objective way to assess readiness for ambulation.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is A

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 collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider finds no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage this behavior?

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?

A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?

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

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

As clients age. skin goes through several changes. Which of the following identifies a change you may see in an elderly client's skin?