A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Ulcerative colitis.

Appendicitis.

Peritonitis.

Diverticulitis.

Answer and Explanation

The Correct Answer is C

Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.

A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.

B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.

D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.

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Correct Answer is A

Explanation

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

A. Speak before touching the client. B. Provide the client with a see-eye guide dog. C. Allow client to follow your lead. D. Provide a detailed description of the room and walkway.

Correct Answer is C

Explanation

Allow the client to follow your lead. This technique would be most beneficial for the ambulation of a visually impaired client. The nurse should allow the client to follow their lead because they are more familiar with their surroundings and can navigate better.

Option A, speaking before touching the client, is appropriate but not as effective as allowing the client to follow the nurse's lead.

Option B, providing a see-eye guide dog, may not always be feasible.

Option D, providing a detailed description of the room and walkway, may be helpful but not as effective as allowing the client to follow the nurse's lead.

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A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Correct Answer is A

Explanation

Which technique would be most beneficial for ambulation of a client who is visually impaired?

Correct Answer is C

Explanation

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