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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This is not the best response because it is alarmist and does not address the client's concern. The nurse should not assume that the client needs to have their medications adjusted or be admitted to the hospital without further assessment.

Choice B reason: This is not the best response because it is inaccurate and does not explain the link between urine retention and confusion. The nurse should not imply that the client is causing their own confusion by not drinking enough water.

Choice C reason: This is the best response because it is accurate and educates the client on the effects of dehydration on the body. The nurse should encourage the client to drink more fluids throughout the day and offer strategies to make it easier for them to access the bathroom at night.

Choice D reason: This is not the best response because it is irrelevant and does not address the client's dehydration. The nurse should not suggest that the client has a urinary tract infection without evidence or testing. The nurse should also not discourage the client from urinating at night, as this can lead to other complications.

A. MRI B. Esophagogastroduodenoscopy (EGD) C. Colonoscopy D. Computed tomography (CT) scan

Correct Answer is B

Explanation

Choice A reason: MRI is not a diagnostic procedure for Barrett esophagus. MRI is a type of imaging test that uses magnetic fields and radio waves to create detailed pictures of the internal organs and tissues. It is mainly used to diagnose problems in the brain, spine, joints, and blood vessels.

Choice B reason: EGD is a diagnostic procedure for Barrett esophagus. EGD is a type of endoscopy that uses a flexible tube with a light and a camera to examine the esophagus, stomach, and duodenum. It can detect changes in the lining of the esophagus that may indicate Barrett esophagus, a condition where the normal squamous cells are replaced by columnar cells due to chronic acid exposure.

Choice C reason: Colonoscopy is not a diagnostic procedure for Barrett esophagus. Colonoscopy is a type of endoscopy that uses a flexible tube with a light and a camera to examine the colon and rectum. It is mainly used to screen for colorectal cancer and polyps, as well as to diagnose inflammatory bowel disease and other conditions affecting the lower gastrointestinal tract.

Choice D reason: CT scan is not a diagnostic procedure for Barrett esophagus. CT scan is a type of imaging test that uses X-rays and a computer to create cross-sectional pictures of the body. It is mainly used to diagnose problems in the chest, abdomen, pelvis, and bones.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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