A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Sounds are high-pitched

Can be a result of a paralytic ileus

Indicates decreased motility

Sounds are soft and at a rate of 1/min

Answer and Explanation

The Correct Answer is A

Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.

Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.

Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.

Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.

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Correct Answer is C

Explanation

Children often have difficulty understanding the complex nature of illness and death. They may develop feelings of guilt or responsibility for the situation, thinking that their behavior or actions caused the illness or its outcome.

It is important for the nurse to provide support, reassurance, and age-appropriate explanations to address the sibling's concerns and misconceptions.

A. Apply rubber-soled slippers before ambulation. B. Move the bedside table with the client's personal items close to the bed. C. Determine the client's ability to use the call light. D. Create a schedule with an assistive personnel to do hourly rounding for the client.

Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

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A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

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