A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Call the primary provider and report that the client may be obstructed.
Position the client supine and insert an NG tube.
Administer a fleet enema as prescribed and remain with the client.
Contact the primary provider promptly and report these signs of perforation.
The Correct Answer is D
Choice A reason: This is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.
Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.
Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.
Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.
Correct Answer is B
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client should avoid alcohol and other substances that can harm the liver, as adalimumab can increase the risk of liver toxicity and hepatitis.
Choice B reason: This is a statement that indicates a need for further teaching. The client should not take naproxen and aspirin as needed for pain relief, as these are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding and gastrointestinal ulcers. Adalimumab can also increase the risk of bleeding and ulcers, as it suppresses the immune system and the inflammatory response.
Choice C reason: This is not a statement that indicates a need for further teaching. The client should report any signs of infection or fever to the doctor, as adalimumab can increase the risk of serious infections and sepsis. Adalimumab can also mask the symptoms of infection, such as inflammation and pain.
Choice D reason: This is not a statement that indicates a need for further teaching. The client should inject the medication under the skin of the abdomen or thigh, as this is the recommended route and site for adalimumab administration.
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