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. Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B. A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C. Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D. A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.

A. Record the findings in the client's record. B. Clean the ears to remove excess wax build up. C. Referral to an audiologist for a hearing evaluation. D. Culture the white patches for possible fungal growth.

Correct Answer is A

Explanation

A. This is an appropriate first step in documenting any unusual findings during the assessment. However, based on the presence of dense white patches, the nurse should consider a referral for further evaluation, rather than just recording the findings.
B. The dense white patches seen on the tympanic membrane are more likely related to past ear infections (such as tympanosclerosis) or other conditions, not excess wax. Cleaning the ears would not address the underlying cause and could potentially cause harm.
C. This could be a reasonable action if there were concerns about hearing loss. However, the tympanic membranes appear mostly normal apart from the white patches, so hearing loss is not strongly indicated by the findings alone. A referral might be premature unless hearing issues are suspected.
D. The dense white patches on the tympanic membranes could be indicative of tympanosclerosis, a benign condition related to previous infections or tube insertions, but fungal growth is not the most likely cause in this case.

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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

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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