A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Hypoactivity

Paralytic ileus

Borborygmi

Distention

Answer and Explanation

The Correct Answer is C

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

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Correct Answer is ["B","D","E","F"]

Explanation

A. Administer an antibiotic: There is no indication of infection; WBC count is normal, and the client is afebrile. The reported symptoms relate to lifestyle and substance use rather than a bacterial illness, making antibiotics unnecessary.

B. Limit alcohol intake to 2 drinks per day: The client uses 4–5 beers nightly to sleep, indicating alcohol misuse that can exacerbate hypertension and negatively impact sleep quality. Limiting intake supports cardiovascular and liver health, and aligns with public health recommendations.

C. Limit foods high in potassium: The client’s potassium level is within the normal range (3.7 mEq/L), and there is no evidence of kidney dysfunction or hyperkalemia. Restricting potassium is unwarranted and could risk deficiency.

D. Administer a diuretic: The client has elevated blood pressure (162/90 mm Hg), which may require pharmacologic intervention. Diuretics are a common first-line treatment for hypertension as they reduce fluid overload and vascular resistance.

E. Keep daily fat intake to less than 35%: The client’s LDL (210 mg/dL) and total cholesterol (248 mg/dL) levels are significantly elevated. Reducing total fat intake, particularly saturated fats, is essential for lowering cholesterol and reducing cardiovascular risk.

F. Place on 2,300 mg sodium diet: A sodium-restricted diet is standard for managing hypertension. The American Heart Association recommends limiting sodium to help control blood pressure and reduce cardiovascular complications.

A. Room number B. Photo identification C. Diagnosis D. Facility-assigned identification number E. Date of birth

Correct Answer is ["B","D","E"]

Explanation

A. Room number: Room number is not a reliable client identifier because clients can be moved or rooms reassigned, which increases the risk of medication errors or misidentification.

B. Photo identification: Using photo identification is a reliable way to confirm the client’s identity, ensuring that medications are given to the correct person by visually matching the client’s face.

C. Diagnosis: Diagnosis alone is not a unique identifier since multiple clients can share the same diagnosis, and it does not confirm identity for medication administration purposes.

D. Facility-assigned identification number: This number is a unique identifier assigned to each client and is commonly used in healthcare settings to verify identity accurately before medication administration.

E. Date of birth: Date of birth is a reliable identifier to cross-check client identity, especially when used with other identifiers, reducing the risk of errors during medication administration.

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A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Nursing Test Bank

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