A nurse is assessing a client who has an obstruction in the small intestine. Clinical manifestations that the nurse would expect include: (SELECT ALL THAT APPLY)
Fecal-smelling breath.
Severe abdominal distention.
Weakness, weight loss, and anorexia.
High-pitched tinkling bowel sounds.
Intense thirst.
Correct Answer : A,B,D
Choice A rationale
Fecal-smelling breath is a symptom of small intestine obstruction due to bacterial fermentation of trapped food, which produces a foul odor that can be detected on the breath.
Choice B rationale
Severe abdominal distention occurs in small intestine obstructions because of the accumulation of gas and fluids proximal to the obstruction site, leading to a noticeable increase in abdominal girth.
Choice C rationale
Weakness, weight loss, and anorexia are more characteristic of chronic gastrointestinal conditions rather than acute small intestine obstruction. These symptoms develop over a longer period and are not acute manifestations.
Choice D rationale
High-pitched tinkling bowel sounds are a typical finding in small intestine obstruction. They occur due to increased peristaltic activity proximal to the obstruction site as the intestines attempt to move the obstructed contents.
Choice E rationale
Intense thirst is not a primary manifestation of small intestine obstruction. While dehydration can occur, it is not specific to small intestine obstruction and can be a result of many other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Medical asepsis does not kill all organisms; it reduces the number of pathogens to a safe level. Complete sterilization, which kills all organisms, is a characteristic of surgical asepsis.
Choice B rationale
Medical asepsis does not require the use of sterile attire to protect the patient. This is a practice associated with surgical asepsis to maintain a sterile field during surgical procedures.
Choice C rationale
Medical asepsis is not confined to the patient's room. It involves practices that reduce the risk of infection in various healthcare settings, not just in the patient's room.
Choice D rationale
Medical asepsis involves the use of sterile equipment before contact with the patient to reduce the risk of infection. This is a practice aimed at maintaining a clean environment and preventing the spread of pathogens. .
Correct Answer is D
Explanation
Choice A rationale
Opening the sterile tray by first unfolding the flap furthest from the body is a correct practice to avoid reaching over the sterile field, which helps maintain the sterility of the field.
Choice B rationale
Holding a sterile item just above waist level is appropriate as long as the item remains within the sterile field's boundaries. Keeping items at this level helps prevent accidental contamination from lower surfaces.
Choice C rationale
Placing a sterile dressing 5 cm (2 in) from the border of the sterile field is acceptable, as the border is considered non-sterile, and maintaining this distance helps ensure the sterility of the item within the field.
Choice D rationale
Opening a sterile package directly over the middle of the sterile field can lead to contamination. Any particles or contaminants from the package may fall into the sterile field, compromising its sterility. .
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