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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Offer the client a small meal if she is not nauseated:
While eating a small meal can help raise blood glucose levels, it is not the immediate priority in a severe hypoglycemia situation. The client might be unconscious or unable to swallow safely, making this action inappropriate as a first step.
B) Administer 1 mg of glucagon intramuscularly to the client:
Administering glucagon intramuscularly is the most crucial initial action. Glucagon rapidly increases blood glucose levels by stimulating glycogen breakdown in the liver. This is vital for quickly reversing severe hypoglycemia, especially if the client is unconscious or unable to ingest carbohydrates orally.
C) Contact the client's provider for further instructions:
Contacting the provider is essential, but it should occur after addressing the immediate hypoglycemic episode. Once the client's condition stabilizes, further guidance can be sought from the healthcare provider.
D) Transport the client to an emergency department for treatment:
Transporting the client to the emergency department is necessary if the hypoglycemia does not improve after administering glucagon or if the client remains unresponsive. However, it is not the first action; immediate glucagon administration takes precedence to stabilize the client's condition before considering transportation.
Correct Answer is C
Explanation
A. Discuss events with the child that have led to anxiety in the past.: While understanding past anxiety triggers can be helpful, focusing on specific strategies and action plans is more effective for managing current anxiety.
B. Assure the child that he is in control of the situation.: This might not always be accurate or helpful. Reassuring the child may not address the underlying anxiety or provide practical strategies for managing it.
C. Provide the child with a detailed action plan when he becomes anxious.: This approach is beneficial as it gives the child a structured plan to follow, which can help manage anxiety and provide a sense of control. Specific actions can help the child cope with anxiety in real-time.
D. Leave the child alone when he is exhibiting signs of anxiety.: Avoiding the child during episodes of anxiety can increase feelings of isolation and might not address the child's needs for support and guidance during these times.
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