GI & GU
An 80-year-old client reports frequent constipation and bloating. The abdomen is soft and non-distended with hypoactive bowel sounds. What age-related change explains this finding?
Decreased intestinal peristalsis, which slows stool transit and leads to constipation
The nurse prepares to assess a client’s abdomen. In what sequence should the assessment techniques occur, and why is this order important?
Inspection → Auscultation → Percussion → Palpation; auscultation is done before touching to avoid altering bowel sounds
The nurse documents: “PERRLA.” What does this abbreviation stand for and what does it confirm about the client’s neurological status?
Pupils Equal, Round, Reactive to Light and Accommodation, confirming intact cranial nerves II and III and normal eye response
When assessing heart sounds, where is the point of maximal impulse (PMI) located, and what information does it provide?
5th intercostal space, left midclavicular line; it reflects left ventricular contraction strength and rhythm
A client starting tamsulosin for BPH asks what side effects to watch for. What teaching should the nurse provide?
Rise slowly from sitting or lying positions to prevent dizziness from orthostatic hypotension
A client presents with 4 days of watery diarrhea and difficulty keeping fluids down. The nurse notes dry mucous membranes and decreased urine output. What condition should the nurse suspect?
Dehydration related to excessive fluid loss from the GI tract
The nurse listens for bowel sounds and hears nothing. How long should the nurse continue before determining that bowel sounds are absent?
A total of 5 minutes, listening at least 1 minute per quadrant before declaring sounds absent
During a cranial nerve assessment, the nurse asks the client to follow an object through the six cardinal fields of gaze. Which cranial nerves are tested?
Cranial nerves III (Oculomotor), IV (Trochlear), and VI (Abducens), which coordinate eye movement
When percussing the lungs, the nurse hears a resonant tone. What does this finding indicate?
Normal, air-filled lung tissue, suggesting healthy ventilation
The nurse teaches a client about docusate sodium. What should be included in the teaching regarding its action and use?
It’s a stool softener that allows water and fats to penetrate stool, easing passage. Encourage adequate hydration
A client with renal calculi asks how to prevent recurrence. The nurse reinforces education. What is the most important daily recommendation?
Encourage 2,000–3,000 mL of fluids daily to promote urine flow and prevent stone formation
During a physical exam, which assessment technique allows the nurse to determine the density of an organ or underlying structure?
Percussion, which helps identify air, fluid, or solid masses below the surface
A parent asks why their infant gets ear infections so often. What anatomical difference explains this?
Infants have a shorter, more horizontal Eustachian tube, allowing easier bacterial migration from the nasopharynx
During auscultation, the nurse hears continuous, high-pitched squeaky sounds louder on expiration. What type of breath sound is this, and what does it suggest?
Wheezes, caused by narrowed airways from bronchospasm, common in asthma
The nurse instructs a client prescribed sennosides (Senna). How does this medication promote bowel elimination?
It is a stimulant laxative that increases peristalsis in the colon, usually producing a BM within 6–12 hours
A client with urinary incontinence asks about diet changes. Which food or drink should the nurse teach them to avoid and why?
Caffeinated beverages, such as coffee or tea, because they irritate the bladder and increase urgency
While inspecting skin during a head-to-toe assessment, what two primary factors does the nurse assess, and why are they important?
Color and presence of lesions to identify circulation, oxygenation, and potential skin breakdown
A client with otitis media suddenly reports that ear pain has stopped and purulent drainage has begun. What should the nurse suspect?
Perforation of the tympanic membrane, which relieves pressure but allows fluid discharge
The nurse switches from the diaphragm to the bell of the stethoscope while assessing the heart. What sounds is the bell designed to detect?
Low-pitched sounds, such as S3, S4, and certain murmurs like mitral stenosis
The client asks what clotrimazole cream is used for. What should the nurse explain?
It treats fungal infections such as athlete’s foot, ringworm, and yeast infections of the skin
An older male reports weak urine stream, hesitancy, and frequent nighttime urination. What condition do these findings suggest, and what causes it?
Benign Prostatic Hyperplasia (BPH), caused by prostate enlargement that compresses the urethra and obstructs urine flow
The nurse presses on a client’s shin and observes a 4 mm indentation lasting about 10–15 seconds. How should this be documented, and what does it indicate?
2+ pitting edema, reflecting moderate fluid retention that resolves in under 15 seconds
A child presents with thick yellow discharge causing eyelids to stick shut in the morning. Which type of conjunctivitis does this suggest and how is it treated?
Bacterial conjunctivitis, treated with antibiotic eye drops and exclusion from school until 24 hours after therapy begins
When locating Erb’s Point, where should the nurse place the stethoscope, and what is commonly heard there?
Left 3rd intercostal space at the sternal border; S1 and S2 are heard equally at this landmark
A client taking metoclopramide for nausea develops lip-smacking and involuntary chewing movements. What is the nurse’s priority action?
Hold the medication and notify the provider immediately, as this indicates tardive dyskinesia, a serious adverse effect