A nurse is assessing a client who has a complete small bowel obstruction. Which of the following manifestations should the nurse expect? (Select all that apply.)
Urticaria
Vomiting
Distended abdomen
Fluid overload
Obstipation
Correct Answer : B,C,E
A) Urticaria:
Urticaria, or hives, is a skin reaction characterized by itchy, raised welts. It is not typically associated with a small bowel obstruction, which primarily affects the gastrointestinal system rather than the skin.
B) Vomiting:
Vomiting is a common symptom of a complete small bowel obstruction. It occurs due to the blockage in the intestines, which prevents the passage of contents, leading to nausea and vomiting as the body tries to expel the obstruction.
C) Distended abdomen:
A distended abdomen is expected in cases of small bowel obstruction. The blockage causes a buildup of gas and fluids, leading to abdominal swelling and distention as the normal passage of intestinal contents is impeded.
D) Fluid overload:
Fluid overload is not a typical manifestation of a small bowel obstruction. Instead, dehydration and electrolyte imbalances are more likely due to vomiting and the inability to absorb fluids and nutrients properly.
E) Obstipation:
Obstipation, or severe constipation with an inability to pass stool or gas, is a key sign of a complete small bowel obstruction. The obstruction prevents the normal movement of intestinal contents, leading to a cessation of bowel movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Lymphocytes 30%:
Lymphocyte levels are typically elevated during the acute phase of mononucleosis as the body fights the Epstein-Barr virus. A level of 30% indicates that the lymphocyte count is returning to a more normal range, which suggests the client is recovering from the infection.
B) RBC 4.4:
The red blood cell count is not directly indicative of recovery from mononucleosis. While it provides information about the client's overall hematologic status, it does not specifically reflect the status of the viral infection.
C) Hgb 14 g/dL:
Hemoglobin levels can provide information about the client's oxygen-carrying capacity but do not specifically indicate recovery from mononucleosis. Normal hemoglobin levels are reassuring but not directly related to the viral infection's resolution.
D) Hct 42%:
Hematocrit levels, like hemoglobin, offer information about the client's blood composition but do not directly indicate recovery from mononucleosis. While normal hematocrit levels are desirable, they are not specific to the recovery status of the viral illness.
Correct Answer is C
Explanation
A) Hematocrit 37% is within the normal range for adults, indicating that the client’s red blood cell volume is adequate. While anemia can be a concern in clients with Crohn's disease, this value does not specifically indicate malnutrition.
B) Iron 160 mcg/dL is above the normal range (typically 50-170 mcg/dL). Elevated iron levels can result from supplementation or other factors, but it does not directly indicate malnutrition. Iron status alone is not a reliable marker for overall nutritional status.
C) Prealbumin 9 mg/dL is significantly below the normal range (15-36 mg/dL). Low prealbumin levels are a strong indicator of malnutrition because prealbumin has a short half-life and reflects recent changes in protein status and dietary intake. This result suggests the client has been experiencing inadequate nutritional intake or absorption.
D) C-reactive protein (CRP) 15 mg/L indicates inflammation, which is common during an exacerbation of Crohn's disease. While elevated CRP levels signal active inflammation, they do not specifically indicate malnutrition. CRP is more commonly used as a marker of inflammatory activity rather than nutritional status.
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