The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

Severe fluid and electrolyte imbalance

Upper abdominal distention

Metabolic acidosis

Projectile vomiting with a fecal odor

Diarrhea or ribbon-like stools

Answer and Explanation

Correct Answer : A,B,D

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Correct Answer is A

Explanation

Choice A reason:Testing the drainage for the halo sign is the first action the nurse should take, as clear drainage from the nose following a basal skull fracture could indicate a cerebrospinal fluid (CSF) leak, which contains glucose.

Choice B reason:Asking the client to blow his nose could potentially increase the risk of infection or worsen a CSF leak and is not recommended as a first action.

Choice C reason:While notifying the physician is important, it should be done after confirming whether the drainage is CSF, which would require immediate medical intervention.

Choice D reason:Suctioning the nostril is not the first action to take, as it could potentially disrupt the site of the leak and is not diagnostic of a CSF leak.

A. Frequent nosebleeds and bruising B. Urinary retention C. No bowel movement in three days D. Increased blood glucose

Correct Answer is A

Explanation

Choice A reason: Frequent nosebleeds and bruising are indicative of coagulopathy, a common complication in advanced cirrhosis due to the liver's impaired ability to synthesize clotting factors. This can lead to an increased tendency to bleed.

Choice B reason: Urinary retention is not typically associated with cirrhosis. Instead, cirrhosis can lead to renal dysfunction known as hepatorenal syndrome, characterized by the failure of the kidneys to filter waste from the blood².

Choice C reason: While constipation can occur in cirrhosis, no bowel movement in three days is not a direct complication of cirrhosis. However, it could be related to the overall health status of the patient or medications used.

Choice D reason: Increased blood glucose is not a direct complication of cirrhosis. Cirrhosis primarily affects the metabolism of proteins and fats and does not directly cause hyperglycemia unless there is concurrent diabetes or metabolic syndrome.

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The nurse is caring for a client who has a small bowel obstruction. When teaching the student nurse about this condition, the nurse will include which of the following findings that are consistent with the diagnosis? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

The nurse is caring for a client with advanced cirrhosis. Which of the following clinical manifestations should the nurse recognize as a serious complication of this condition?

Correct Answer is A

Explanation

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