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 D

Explanation

Choice A reason: This is not a correct finding for hypovolemia. Peripheral edema is the swelling of the extremities due to fluid accumulation in the interstitial spaces. It is a sign of fluid volume excess, not fluid volume deficit.

Choice B reason: This is not a correct finding for hypovolemia. Bradycardia is a slow heart rate, usually below 60 beats per minute. It is not a typical sign of fluid volume deficit, as the heart rate usually increases to compensate for the low blood pressure and low cardiac output.

Choice C reason: This is not a correct finding for hypovolemia. Hypertension is a high blood pressure, usually above 140/90 mmHg. It is not a typical sign of fluid volume deficit, as the blood pressure usually decreases due to the reduced blood volume and vascular resistance.

Choice D reason: This is a correct finding for hypovolemia. Decreased urine output is a sign of fluid volume deficit, as the kidneys try to conserve water and electrolytes by reducing the urine production. The normal urine output is about 30 mL per hour, and anything below 20 mL per hour is considered oliguria, which indicates impaired renal function.

A. Active transport B. Diffusion C. Filtration D. Osmosis

Correct Answer is B

Explanation

Choice A reason: Active transport is the process of moving molecules across a cell membrane against a concentration gradient, requiring energy.

Choice B reason: Diffusion is the process of moving molecules from an area of high concentration to an area of low concentration, without using energy.

Choice C reason: Filtration is the process of moving fluid and solutes through a membrane by a pressure gradient.

Choice D reason: Osmosis is the process of moving water across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

The nurse is providing care for a client with a fluid imbalance. The nurse explains that in the body, areas with high concentration of solutes naturally and passively shift to areas of lower concentration. The nurse is describing which process?

Correct Answer is B

Explanation

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