When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Absent

Blowing sound due to restriction.

A continuous medium pitched sound.

High pitched, tinkling, rushing or growling.

Answer and Explanation

The Correct Answer is D

A. Absent. Borborygmus refers to hyperactive bowel sounds, not absent sounds.

B. Blowing sound due to restriction. A blowing sound may indicate a vascular issue, such as a bruit over the aorta, rather than bowel motility.

C. A continuous medium-pitched sound. Medium-pitched sounds may be heard in normal bowel activity, but borborygmus refers to increased, hyperactive sounds.

D. High-pitched, tinkling, rushing, or growling. Borborygmus describes hyperactive bowel sounds, which occur in conditions such as gastroenteritis or hunger.

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Correct Answer is C

Explanation

A. Denial of pruritus. Pruritus (itching) is a hallmark symptom of contact dermatitis, so its denial would be unusual.

B. Reports of joint discomfort. Joint pain is not a characteristic feature of contact dermatitis; it is more common in systemic inflammatory conditions such as arthritis.

C. Reports of exposure to a skin irritant. Contact dermatitis is caused by direct contact with an irritant or allergen, so a history of exposure is a key finding.

D. Elevated temperature. Fever is not typical of contact dermatitis unless an infection is present.

A. Ask the client to push her legs and feet against the nurse's palms. B. Check the client's pedal pulses and feet for edema. C. Ask the client if she has been out of bed today. D. Ask the client how strong she feels today.

Correct Answer is A

Explanation

A. Ask the client to push her legs and feet against the nurse's palms. This action directly assesses the client’s muscle strength and ability to bear weight, which is essential before ambulation.

B. Check the client's pedal pulses and feet for edema. While circulatory assessment is important, it does not assess muscle strength, which is needed for safe ambulation.

C. Ask the client if she has been out of bed today. The client’s response does not objectively measure strength or readiness for ambulation.

D. Ask the client how strong she feels today. A client’s perception of strength may not be accurate and is not an objective way to assess readiness for ambulation.

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When reviewing the medical record of a newly assigned client, the nurse notes borborygmus documented to describe bowel sounds on the previous abdominal assessment. The nurse knows this means that the client's bowel sounds were what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is A

Explanation

A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

A nurse is collecting data from a client who is experiencing stress. Which of the following findings should indicate to the nurse ineffective coping?

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?

A nurse is caring for a client who has impaired renal function. The nurse should notify the provider if the client's hourly urine output falls below what amount? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?

A nurse is caring for a client who tells the nurse she experiences urinary incontinence when she sneezes. The nurse recognizes this is an expected finding for which of the following types of incontinence?