Which characterizes auscultation of the abdomen?

Correct Answer: A

Rationale: The correct answer is A) The presence of borborygmi indicates hyperperistalsis. Auscultation of the abdomen is a crucial component of the physical examination to assess gastrointestinal function. Borborygmi refers to the rumbling or gurgling noises produced by hyperactive bowel sounds, indicating increased intestinal peristalsis. This finding can be indicative of various conditions such as diarrhea, gastroenteritis, or early bowel obstruction. Option B) is incorrect because the diaphragm, not the bell, of the stethoscope is used to auscultate high-pitched sounds in the abdomen. The diaphragm is better at detecting higher-frequency sounds, which are typically heard in the abdomen. Option C) is vague and does not provide a specific characteristic of abdominal auscultation. High-pitched sounds can be present in normal bowel sounds as well as abnormal ones, so it does not accurately describe a hallmark finding. Option D) rushing is also too vague and does not provide a specific characteristic of abdominal auscultation. It does not relate to the specific sound of borborygmi or any other typical bowel sound. Educationally, understanding the significance of borborygmi in auscultation helps healthcare providers in diagnosing and monitoring gastrointestinal conditions. It underscores the importance of thorough physical examination skills in assessing patients comprehensively. Learning to differentiate various bowel sounds and their implications is essential for healthcare professionals in providing quality patient care.

Correct Answer: C

Rationale: The correct answer to the question is C) Recurrent herpes simplex infections. This is the right choice because oral herpes infections have been associated with an increased risk of oral cancer, particularly in individuals with weakened immune systems. Recurrent herpes infections can lead to chronic inflammation and tissue damage in the oral cavity, which can contribute to the development of oral cancer. Option A) what should the nurse specifically ask the patient about during a history, while important in gathering information, is too broad and does not directly address the risk factor for oral cancer as requested in the question. Option B) Excessive exposure to sunlight is a risk factor for skin cancer, particularly melanoma, and is not directly related to the development of oral cancer. Option D) Use of any type of tobacco products is a well-known risk factor for oral cancer. However, in this case, the question is specifically asking about risk factors related to oral herpes infections and oral cancer. In an educational context, it is important for healthcare providers to be aware of the various risk factors associated with oral cancer to provide comprehensive care to their patients. Understanding how certain conditions or behaviors can increase the likelihood of developing oral cancer allows for early detection, prevention, and appropriate management strategies to be implemented. By knowing the specific risk factors, healthcare professionals can tailor their assessments and interventions to address individual patient needs effectively.

Correct Answer: B

Rationale: In teaching patients at risk for upper GI bleeding to prevent bleeding episodes, it is crucial for the nurse to emphasize that the use of over-the-counter (OTC) medications of any kind should be avoided (Option B). This is the correct answer because many OTC medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and certain supplements, can increase the risk of GI bleeding by irritating the stomach lining or interfering with blood clotting. Option A, testing all stools and vomitus for blood, although important for monitoring, does not address prevention strategies. Option C, taking antacids with prescribed medications, is not a universal preventive measure for upper GI bleeding. Option D, using misoprostol (Cytotec), is a treatment option for protecting the gastric mucosa in certain cases but is not a primary prevention strategy. Educationally, it is essential to teach patients about the potential risks associated with OTC medications and the importance of consulting healthcare providers before taking any new medication, especially if they are at risk for upper GI bleeding. Emphasizing lifestyle modifications, medication management, and regular monitoring can empower patients to take an active role in their health and prevent complications like GI bleeding.

Correct Answer: B

Rationale: In the postoperative assessment of a patient who has undergone the first phase of a total proctocolectomy with ileal pouch and anal anastomosis for ulcerative colitis, the nurse should expect to find a loop ileostomy with a plastic rod to hold it in place. This is because after this surgical procedure, a loop ileostomy is often created temporarily to divert fecal flow while the newly created ileal pouch heals. The plastic rod is used to prevent the stoma from retracting into the abdomen. Option A (rectal tube set to low continuous suction) is incorrect because in this surgical procedure, the colon and rectum are usually removed, so there is no need for a rectal tube. Option C (a colostomy stoma with an NG tube in place to provide pouch irrigations) is incorrect because in this procedure, an ileal pouch is created, not a colostomy stoma. Additionally, irrigations are not typically done in the immediate postoperative period. Option D (a permanent ileostomy stoma in the right lower quadrant of the abdomen) is incorrect because the first phase of a total proctocolectomy with ileal pouch and anal anastomosis does not involve the creation of a permanent ileostomy. Educationally, understanding the postoperative care and expected findings following specific surgical procedures is crucial for nurses caring for patients with gastrointestinal conditions. This knowledge ensures appropriate assessment, intervention, and patient education to promote optimal recovery and outcomes.

Correct Answer: B

Rationale: Short bowel syndrome (SBS) is a condition characterized by malabsorption due to a significant portion of the small intestine being removed or non-functional. The most likely patient to be diagnosed with SBS is the one who had extensive resection of the ileum (Option B) because the ileum is the last part of the small intestine where most nutrient absorption occurs. Removal or dysfunction of a large part of the ileum can lead to malabsorption issues seen in SBS. Option A, a history of ulcerative colitis, is incorrect because ulcerative colitis primarily affects the large intestine and does not directly result in SBS. Option C, irritable bowel syndrome, is a functional disorder and does not involve structural changes in the intestine like SBS. Option D, having a colectomy for bowel cancer, involves the removal of the colon (large intestine), not the small intestine where SBS typically occurs. In an educational context, understanding the specific anatomical and functional roles of different parts of the gastrointestinal tract is essential in diagnosing and managing conditions like short bowel syndrome. It highlights the importance of considering surgical history and its potential impact on nutrient absorption and overall gastrointestinal health.