A nursing student has auscultated a patient's abdomen and noted one or two bowel sounds in a 2-minute period of time. How would you tell the student to document the patient's bowel sounds?
A) Normal
B) Hypoactive
C) Hyperactive
D) Paralytic ileus
Ans: B
Feedback:
Documenting bowel sounds is based on assessment findings. The terms normal (sounds heard about every 5 to 20 seconds), hypoactive (one or two sounds in 2 minutes), hyperactive (5 to 6 sounds heard in less than 30 seconds), or absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.
You might also like to view...
What should the nurse explain when responding to the question, "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?"
a. Early addition of baby food will meet the infant's needs. b. The breast milk will gradually become richer to supply additional calories. c. As the infant requires more milk, feedings can be supplemented with cow's milk. d. The mother's milk supply will increase as the infant demands more at each feeding.
A patient is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago
The nurse recognizes that the patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient seems unable to verbalize needs. 2. The patient has difficulty starting the flow of urine. 3. The patient reports a stiff neck. 4. The patient has a temperature of 101°F. 5. The patient has unequal but reactive pupils.
A patient can be told that she is definitely pregnant when she has:
a. Positive pregnancy results b. Uterine enlargement c. Fetal heart sounds d. Amenorrhea
A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will:
a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.