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. Identify when the client first noticed the lesion. Determining onset and duration helps assess whether the lesion is new, growing, or concerning for malignancy.

B. Photograph the lesion for the client's medical record. While documentation is important, assessing history and changes in the lesion takes priority.

C. Instructing the client on the use of daily sunscreen products. Sunscreen is essential for prevention, but identifying and assessing the lesion comes first.

D. Document the client's history of skin allergies. While important, it does not take priority over determining how long the lesion has been present and whether it is changing.

A. "Right now, I can't bathe or dress myself, but my family will help me." B. "I can always come stay in the hospital again if I don't want to take care of my own needs." C. "Taking care of myself is important, but it's okay if I don't want to do anything." D. "I will take my medicines as I should and know who to call if I have bad thoughts."

Correct Answer is D

Explanation

A. "Right now, I can't bathe or dress myself, but my family will help me." Dependence on family for basic self-care suggests the client is not yet independent enough for discharge.

B. "I can always come stay in the hospital again if I don't want to take care of my own needs." This statement shows a lack of commitment to self-care and reliance on hospitalization as a coping mechanism.

C. "Taking care of myself is important, but it's okay if I don't want to do anything." Readiness for discharge includes a commitment to self-care, and this statement suggests a lack of motivation.

D. "I will take my medicines as I should and know who to call if I have bad thoughts." This statement shows insight into the importance of medication adherence and knowledge of available support resources, indicating readiness for discharge.

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

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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