A nurse is setting health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should be included in the plan?

Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale

Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.

Choice A rationale

Peptic ulcer disease is not a common complication of difficulty swallowing after a stroke. It is typically caused by an infection with the bacterium Helicobacter pylori or long-term use of nonsteroidal anti-inflammatory drugs.
Choice B rationale
Dumping syndrome is not a common complication of difficulty swallowing after a stroke. It is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight.
Choice C rationale
Aspiration is a common problem for people with dysphagia, a condition that can occur after a stroke. It occurs when something you’ve swallowed enters the airway and lungs. Normally, aspiration causes a violent cough, but a stroke can reduce sensation. In this case, you may not know you’re aspirating (silent aspiration)5.
Choice D rationale
Gastroesophageal reflux disease (GERD) is not a common complication of difficulty swallowing after a stroke. GERD is a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining.