Question

The nurse is palpating the client's abdomen. Which finding should the nurse report to the health care provider immediately? A client

A.who has borborygmus who demonstrates guarding on exam.

B.who reports one day of not having a bowel movement

C.who has high pitched gurgling sounds of 5−30 /minute

Answer 1

A nurse should immediately report if a client demonstrates guarding upon palpation of their abdomen as it could indicate a serious underlying condition. Borborygmus and high-pitched gurgling sounds are typically normal, while a lack of bowel movement for one day is usually not concerning by itself.

Step-by-step explanation:

The nurse should report to the health care provider immediately if a client demonstrates guarding on exam. Guarding is an involuntary reaction to abdominal pain in which the muscles of the client's abdomen tense up upon palpation and can indicate serious underlying conditions such as peritonitis or acute abdomen. Borborygmus is a normal finding of rumbling or gurgling sounds made by the movement of fluid and gas in the intestines and typically does not require immediate action. A client who reports not having a bowel movement for one day is generally not concerning unless accompanied by other symptoms. High pitched gurgling sounds of 5−30 per minute are within the normal range for bowel sounds and are not typically reported to a health care provider immediately.