The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears a gurgling sound every ten seconds. Which action should the nurse take in response to this finding?

Observe the next bowel movement for signs of bleeding.

Encourage increased consumption of fiber in the diet.

Report the hyperactivity to the healthcare provider (HCP).

Document this normal bowel sound activity in the record.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Observe the next bowel movement for signs of bleeding: Monitoring stool for blood is important if gastrointestinal bleeding is suspected, but normal gurgling bowel sounds do not suggest bleeding. This action is unnecessary based solely on the auscultated finding described.

B. Encourage increased consumption of fiber in the diet: Fiber intake is recommended for promoting healthy bowel habits, but the presence of normal bowel sounds does not indicate a need to change dietary habits unless other issues, like constipation, are reported.

C. Report the hyperactivity to the healthcare provider (HCP): A gurgling sound every ten seconds is considered a normal bowel sound frequency. Hyperactive bowel sounds would be continuous, high-pitched, and frequent; therefore, this finding does not require reporting as abnormal.

D. Document this normal bowel sound activity in the record: Bowel sounds occurring every 5 to 15 seconds are typical for a healthy adult. Hearing a gurgling sound every ten seconds reflects normal gastrointestinal motility and should be documented accurately in the client’s health record.

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Correct Answer is C

Explanation

Rationale:
A. An overactive bladder: Overactive bladder typically presents with urgency, frequency, and sometimes incontinence, but it does not usually cause suprapubic tenderness or the sensation of incomplete bladder emptying. These symptoms are more consistent with urinary retention or bladder outlet obstruction.

B. A cloudy discharge: Cloudy urinary discharge is more indicative of a urinary tract infection (UTI) rather than urinary retention. While infections can cause some bladder discomfort, the client’s description points more specifically to mechanical urinary issues rather than infection.

C. A weak urinary stream: A weak urinary stream is commonly associated with bladder outlet obstruction, often due to benign prostatic hyperplasia (BPH) in older males. The combination of suprapubic tenderness and the feeling of incomplete emptying aligns with urinary retention caused by obstruction, making this the expected additional finding.

D. Black tarry stools: Black tarry stools are usually a sign of gastrointestinal bleeding, particularly from the upper GI tract. They are unrelated to urinary symptoms and would not explain suprapubic tenderness or voiding difficulties described by the client.

A. Multiple varicosities on both thighs. B. Stage 2 pressure injury over the left ankle. C. Right calf swelling and tenderness. D. Lack of hair growth on both lower legs

Correct Answer is C

Explanation

Rationale:
A. Multiple varicosities on both thighs: Varicose veins indicate chronic venous insufficiency and poor venous return but are generally not emergencies. They require monitoring and supportive management but do not typically demand immediate intervention unless complications arise.

B. Stage 2 pressure injury over the left ankle: A stage 2 pressure injury is a serious concern that needs proper wound care and prevention strategies. However, it is not an immediate life-threatening condition requiring urgent action compared to findings that suggest a thrombotic event.

C. Right calf swelling and tenderness: Swelling and tenderness in one calf are hallmark signs of deep vein thrombosis (DVT), a condition that can lead to life-threatening pulmonary embolism if the clot dislodges. Immediate intervention is critical to prevent serious complications and initiate anticoagulation therapy if confirmed.

D. Lack of hair growth on both lower legs: Absent hair growth suggests chronic arterial insufficiency or poor circulation, which warrants evaluation but is a chronic finding rather than an acute issue that demands emergency intervention.

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The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears a gurgling sound every ten seconds. Which action should the nurse take in response to this finding?

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Correct Answer is C

Explanation

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Correct Answer is C

Explanation

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