The absence of bowel sounds is established after listening for:

2 full minutes.

1 full minute.

5 full mutes.

1 1/2 minutes.

Answer and Explanation

The Correct Answer is C

A. 2 full minutes: Listening for 2 minutes is insufficient to determine the absence of bowel sounds reliably.

B. 1 full minute: One minute is also too brief, as bowel sounds can sometimes be infrequent, especially in certain conditions.

C. 5 full minutes. The absence of bowel sounds is confirmed after listening in each quadrant for a minimum of 5 full minutes. This is necessary to ensure that the lack of sounds is not due to temporary decreased activity and is instead a true absence, which may indicate a medical emergency like a bowel obstruction.

D. 1 1/2 minutes: This time is not long enough to confirm the absence of bowel sounds accurately.

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Correct Answer is C

Explanation

A. "Most people in your situation are able to get through this.": This statement is dismissive and may minimize the client’s feelings, as it generalizes the experience.

B. "Why do you think you're feeling so alone?": Asking "why" may make the client feel defensive and pressured to justify their feelings, which is not therapeutic.

C. "Do you have anyone you can talk to about your diagnosis?" This response encourages the client to reflect on their support system, which may help reduce feelings of isolation. It also shows empathy and invites further conversation without making assumptions.

D. "I am so sorry about your diagnosis. You must be devastated.": While it shows sympathy, it assumes the client’s feelings and may inadvertently heighten the client’s sense of distress without providing support.

A. The client is terminally ill. B. The client is incapable of providing self-care. C. The client is unable to express their wishes. D. The client has refused treatment.

Correct Answer is C

Explanation

A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.

B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.

C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.

D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.

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The absence of bowel sounds is established after listening for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was recently diagnosed with breast cancer. The client states, "I feel so alone. I don't know how I will be able to deal with this." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is providing information to a client about durable power of attorney. The nurse should include that durable power of attorney is enforceable under which of the following conditions?

Correct Answer is C

Explanation

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