While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Borborygmi sounds.

Hyperactive bowel sounds.

Hypoactive bowel sounds.

Normal bowel sounds.

Answer and Explanation

The Correct Answer is D

A.   Borborygmi refers to the audible rumbling sounds produced by the movement of gas through the intestines. While these sounds may be present in this case, they are more commonly described as prolonged, loud, or audible sounds, not as typical gurgles occurring at the interval described.
B.   Hyperactive bowel sounds are frequent and loud, often heard in conditions like diarrhea or early bowel obstruction. The described pattern here, with sounds occurring every 5 to 10 seconds, doesn't necessarily suggest hyperactivity.
C.   Hypoactive bowel sounds are reduced or absent, commonly seen in conditions like ileus or bowel obstruction. The sounds described here are not consistent with hypoactive sounds, which would be faint or absent.
D.   The description provided aligns with normal bowel sounds, which are intermittent and occur every 5 to 30 seconds in a healthy individual. This pattern of gurgles with the stated frequency is typical of normal bowel function.

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Correct Answer is D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

A. Osteopenia. B. Contracture. C. Atrophy. D. Kyphosis. E. Crepitus.

Correct Answer is ["B","C","D"]

Explanation

A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.

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While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Correct Answer is D

Explanation

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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