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 D
Explanation
Choice A reason: Drinking a minimum of 12 ounces of fluid with each meal is not recommended for a client who has dumping syndrome. Fluids can increase the gastric volume and accelerate the gastric emptying, leading to more severe symptoms. The nurse should advise the client to drink fluids between meals, not with meals.
Choice B reason: Choosing foods that are high in simple carbohydrates is not recommended for a client who has dumping syndrome. Simple carbohydrates can cause a rapid rise and fall of blood glucose levels, resulting in hypoglycemia and weakness. The nurse should advise the client to choose foods that are high in protein and fat, and low in sugar.
Choice C reason: Staying upright when eating and for 30 minutes afterward is not recommended for a client who has dumping syndrome. This position can facilitate the gastric emptying and worsen the symptoms. The nurse should advise the client to lie down after eating to slow down the gastric emptying.
Choice D reason: Eating several small meals daily spaced at equal intervals is recommended for a client who has dumping syndrome. This can help reduce the gastric volume and pressure, and prevent the rapid delivery of food into the small intestine. The nurse should advise the client to eat four to six small meals per day, and avoid skipping meals.
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.
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