While auscultating the abdomen of a client, the nurse notes increased, loud, gurgling bowel sounds. What would be the nurse's best action?
A. Palpate the abdomen.
B. Percuss the abdomen.
C. Notify the physician.
D. Document the finding as the only action.
C
The presence of increased, loud, gurgling bowel sounds is associated with hypermotility, which can be associated with diarrhea or gastroenteritis. This sound also is heard above a complete in-testinal obstruction, and the physician should be notified because the client requires measures to relieve the obstruction, if present.
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A child has sustained a basilar skull fracture. For which complication should the nurse assess?
1. Cerebral spinal fluid leakage from the nose or ears 2. Headache 3. Transient confusion 4. Periorbital ecchymosis
Planned change is a well-thought-out effort designed to make something happen; all efforts are directed and targeted to produce change. According to Reinkemeyer's stages of planned change, when does planning a community health program occur?
A) Stage 1: Identification and development of a felt need and desire for the change B) Stage 2: Development of a change relationship between the community health nurse and the community C) Stage 3: Clarification or diagnosis of the community's problem, need, or objective D) Stage 4: Examination of alternative routes and tentative goals and intention of actions
The nurse administering medications to clients first checks the MAR to compare information. What information is contained in the MAR? Select all answers that apply
A) Client name B) Client address C) Client birth date D) Medication name E) Administration route F) Scheduled times
The nurse is discussing orlistat (Alli) with a group of women at a community center when one of the participants asks, "What side effects are associated with this drug?" The nurse responds by stating:
1. "Tinnitus and hearing loss are side effects associated with orlistat (Alli)." 2. "Headache with photophobia are side effects associated with orlistat (Alli)." 3. "Flatus with oily stool discharge is a side effect often associated with orlistat (Alli)." 4. "Urinary frequency with urgency is a side effect associated with orlistat (Alli)."