A client with diverticular disease has just returned from a colonoscopy. While conducting an abdominal assessment, the nurse monitors for which of the following as an initial sign of a possible complication of the procedure?
Guarding and rebound tenderness
Nausea and vomiting
Diarrhea
Hyperactive bowel sounds
The Correct Answer is A
Choice A reason: Guarding and rebound tenderness are signs of peritonitis, which is a serious complication of colonoscopy. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can be caused by perforation or puncture of the colon during the colonoscopy, which allows bacteria and fecal matter to enter the peritoneal space. The nurse should monitor the client for signs of peritonitis, such as abdominal pain, rigidity, fever, and leukocytosis.
Choice B reason: Nausea and vomiting are not specific signs of a complication of colonoscopy. They may be caused by other factors, such as the sedation, the bowel preparation, or the ingestion of food or fluids after the procedure. Nausea and vomiting may also be symptoms of other conditions, such as gastroenteritis, food poisoning, or pregnancy.
Choice C reason: Diarrhea is not a sign of a complication of colonoscopy. Diarrhea may be a normal consequence of the bowel preparation, which involves taking laxatives or enemas to clear the colon before the procedure. Diarrhea may also be caused by other factors, such as the ingestion of food or fluids after the procedure, or the presence of an underlying bowel disorder, such as irritable bowel syndrome or inflammatory bowel disease.
Choice D reason: Hyperactive bowel sounds are not a sign of a complication of colonoscopy. Hyperactive bowel sounds may indicate increased peristalsis, which is the movement of the digestive tract. Hyperactive bowel sounds may be a normal response to the bowel preparation, the ingestion of food or fluids after the procedure, or the stimulation of the colon during the colonoscopy. Hyperactive bowel sounds may also be present in conditions such as diarrhea, gastroenteritis, or intestinal obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a correct sign of hypervolemia. Increased thirst and dry mucous membranes are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Choice B reason: This is not a correct sign of hypervolemia. Low blood pressure and increased heart rate are signs of hypovolemic shock, which can occur due to severe fluid loss or hemorrhage.
Choice C reason: This is a correct sign of hypervolemia. Difficulty breathing and weight gain are signs of fluid overload, which can occur due to excessive fluid retention or impaired cardiac function. Difficulty breathing can be caused by pulmonary edema, which is the accumulation of fluid in the lungs. Weight gain can be caused by the increase in total body fluid.
Choice D reason: This is not a correct sign of hypervolemia. Dry cough and poor skin turgor are signs of dehydration or fluid volume deficit, which can occur due to excessive fluid loss or inadequate fluid intake.
Correct Answer is D
Explanation
Choice A reason: This statement does not suggest that further health education is necessary. The client is expressing a realistic concern about the cost of the medication, which may be expensive or not covered by insurance. The nurse should acknowledge the client's financial situation and provide information about possible assistance programs or alternative options.
Choice B reason: This statement does not suggest that further health education is necessary. The client is expressing a reasonable anxiety about the medication, which may have side effects or interactions that require monitoring. The nurse should reassure the client and explain the purpose and frequency of the blood tests, as well as the potential benefits and risks of the medication.
Choice C reason: This statement does not suggest that further health education is necessary. The client is expressing a sense of wonder or skepticism about the medication, which may be uncommon or novel for the treatment of obesity. The nurse should educate the client about how the medication works and what to expect from the treatment, as well as the evidence and research behind it.
Choice D reason: This statement suggests that further health education is necessary. The client is expressing a false or unrealistic expectation about the medication, which is not a magic pill or a substitute for lifestyle changes. The nurse should correct the client and emphasize the importance of following a healthy diet and exercise regimen, as well as the goals and limitations of the medication.
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