A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

abdominal distention

visible peristalsis

hypoactive bowel sounds

occasional diarrhea

flatus

Answer and Explanation

Correct Answer : A

A.   Abdominal distention can occur due to gas accumulation from undigested lactose.
B.   Visible peristalsis is not typically a specific clinical finding associated with lactose intolerance.
C.   Hypoactive bowel sounds are not commonly associated with lactose intolerance.
D.   Occasional diarrhea is a common symptom due to the inability to digest lactose properly.
E.   Flatus or excessive gas production is a common symptom due to the fermentation of undigested lactose by intestinal bacteria.

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Correct Answer is C

Explanation

A. Iron supplements typically lead to darker stools but may not necessarily present as a non-tarry black stool.
B. Dry heaves or vomiting could potentially indicate upper gastrointestinal bleeding but not specifically correlate with non-tarry black stool.
C. Consuming red meat can cause black stools due to its breakdown products, which is a normal finding.
D. Loss of appetite doesn't directly relate to stool color or consistency.

A. 1 minute in the center of the abdomen. B. 10 minutes in each quadrant. C. 1 minute in each quadrant. D. 5 minutes in each quadrant. E. None F. None

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?

Correct Answer is C

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is D

Explanation

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