A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

High-pitched bowel sounds

Abdominal bruit

Bruising on the flank area

Coffee-ground emesis

Answer and Explanation

The Correct Answer is A

A) High-pitched bowel sounds: High-pitched bowel sounds, also known as "tinkling" sounds, are characteristic of mechanical bowel obstructions. These sounds are created by the intestines as they try to move contents past the obstruction, resulting in increased peristaltic activity. In the case of intussusception, where one segment of the intestine telescopes into another, the obstruction can cause these distinctive high-pitched sounds due to the narrowing of the bowel lumen.

B) Abdominal bruit: An abdominal bruit is a swishing sound heard over the abdomen, usually indicating turbulent blood flow through narrowed arteries. It is commonly associated with vascular conditions such as atherosclerosis or renal artery stenosis. It is not related to bowel obstruction, as bowel sounds in obstruction cases are generally due to changes in peristaltic activity rather than blood flow.

C) Bruising on the flank area: Bruising on the flank area, known as Grey Turner's sign, is typically seen in conditions involving retroperitoneal hemorrhage, such as severe pancreatitis or trauma. It is not a symptom of bowel obstruction. Bowel obstruction symptoms generally relate to the gastrointestinal tract and include abdominal pain, distension, and altered bowel sounds.

D) Coffee-ground emesis: Coffee-ground emesis is vomit that appears like coffee grounds, indicating the presence of partially digested blood. This is a sign of upper gastrointestinal bleeding, often due to peptic ulcers or gastritis. In mechanical bowel obstruction, vomiting is more likely to contain bile (bilious vomiting) and may occur if the obstruction is high in the small intestine. The appearance of coffee-ground emesis is not typical for bowel obstructions and indicates a different type of gastrointestinal issue.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A) "Sit with your legs in a dependent position when in a chair."
Sitting with legs in a dependent position can decrease blood flow and increase the risk of clot formation. It's important to elevate the legs when sitting to promote venous return and reduce the risk of deep-vein thrombosis (DVT).

B) "Prevent dehydration by drinking at least 2.5 liters fluids each day."
Staying well-hydrated helps maintain good blood circulation and prevents blood from becoming too viscous, reducing the risk of clot formation. Adequate fluid intake is crucial in preventing DVT.

C) "Massage your calves after sitting for 2 hours."
Massaging the calves is not recommended for someone with a history of DVT, as it may dislodge a clot. Instead, clients should be encouraged to move or stretch their legs regularly to improve circulation.

D) "Roll stretchy nylon stockings down to the upper part of your calves."
Proper use of compression stockings involves wearing them as prescribed, which typically means keeping them fully extended to ensure consistent pressure along the leg. Rolling them down can create a tourniquet effect and is not recommended.

A. Decrease folic acid intake. B. Increase lactose intake. C. Provide a gluten-free diet. D. Provide a low-fat diet.

Correct Answer is D

Explanation

A) Decrease folic acid intake: Decreasing folic acid intake is not advisable for clients with malabsorption syndrome. In fact, clients with malabsorption often require increased folic acid due to poor absorption of nutrients, especially in conditions like celiac disease or other causes of malabsorption.

B) Increase lactose intake: Increasing lactose intake is not appropriate for clients with malabsorption syndrome, particularly if they have lactose intolerance. Lactose can exacerbate symptoms such as diarrhea and steatorrhea in these clients.

C) Provide a gluten-free diet: A gluten-free diet is crucial for clients with celiac disease, which is a type of malabsorption syndrome. However, if the malabsorption syndrome is due to another cause, a gluten-free diet might not address the issue. The focus should be on managing fat intake to reduce steatorrhea.

D) Provide a low-fat diet: A low-fat diet is the most appropriate intervention for managing severe steatorrhea, which is the presence of excess fat in the stool. Reducing fat intake helps to minimize fat malabsorption and the associated symptoms, providing relief from steatorrhea.

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A nurse is assessing a client who has a mechanical bowel obstruction caused by intussusception of the ileum. Which of the following findings should the nurse expect?

Nursing Test Bank

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