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 A

Explanation

A. Assessing the client's functional capacity and identifying potential environmental hazards is essential, especially in older adults, as they may face physical limitations or risks in their environment that could impact their safety and quality of life.
B. Medication history is always important, particularly in older adults who may be taking multiple medications for chronic conditions. However, while relevant, it is not the most critical aspect in this scenario.
C. Differentiating between symptoms of aging and those caused by disease is important for accurate diagnosis and treatment. However, the priority should be to assess the client's overall health and risks related to their daily function and environment.
D. While discussing advance directives is essential for future care planning, it is not the immediate priority in this health history assessment. The focus should be on addressing any current health issues that impact the client’s quality of life.

A. "Refrain from eating or drinking for at least thirty minutes." B. "Lie in a prone position with slightly flexed knees." C. "Exhale slowly through your mouth then hold your breath." D. "Empty your bladder just prior to the examination."

Correct Answer is D

Explanation

A. The client should refrain from eating or drinking for other procedures but not specifically for an abdominal examination unless indicated for tests like ultrasounds.
B. A prone position is not necessary for an abdominal exam; lying on the back is preferred.
C. The client should not hold their breath during the abdominal exam unless asked to assist with specific maneuvers.
D. Having the bladder empty before the examination reduces discomfort and allows for better visualization of the abdominal organs.

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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?

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Correct Answer is A

Explanation

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Correct Answer is D

Explanation

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