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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Normal flora does not function as cell rebuilders. They primarily exist in a symbiotic relationship with the host without directly participating in cell repair processes.

Choice B rationale

While some normal flora aid in digestion, they are not involved in blood production. Blood production is a function of bone marrow and not influenced by normal flora.

Choice C rationale

Normal flora play a crucial role in preventing the colonization of pathogens by competing for nutrients and space, thereby protecting the body from harmful microorganisms.

Choice D rationale

Normal flora do not manage the fluid balance of the body. Fluid balance is regulated by the kidneys and the body's endocrine system, not by the normal flora.

A. Withholding food and fluids until a diagnosis is established. B. Administering prophylactic IV antibiotics. C. Giving the client a heating pad to place on the abdomen for comfort. D. Administering a cleansing enema in preparation for surgery. E. Having the client ambulate at least once every hour.

Correct Answer is ["A","B"]

Explanation

Choice A rationale

Withholding food and fluids is essential to prevent complications should surgery be needed.

Choice B rationale

Administering prophylactic IV antibiotics helps prevent infection, which is critical in cases of appendicitis.

Choice C rationale

Applying heat to the abdomen can increase circulation and the risk of rupture in appendicitis.

Choice D rationale

Administering an enema can increase the risk of perforation in appendicitis.

Choice E rationale

Ambulation can exacerbate pain and the risk of rupture in a client with suspected appendicitis.

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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)

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Naxlex Comprehensive Predictor Exams

The nurse explains that the body's normal flora serves as:

Correct Answer is C

Explanation

The nurse is caring for a client with suspected appendicitis. Nursing interventions for this client would include: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B"]

Explanation

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