A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?
Hyperactive bowel sounds
Increased urinary output
Frequent bowel movements
Rigid abdomen
The Correct Answer is D
Choice A reason: Hyperactive bowel sounds are not typically associated with peritonitis. Instead, peritonitis often leads to decreased or absent bowel sounds due to the inflammation and subsequent ileus (paralysis of the bowel), which slows down or halts peristalsis.
Choice B reason: Increased urinary output is not a common symptom of peritonitis. In fact, peritonitis can sometimes result in reduced urine output due to the body's response to infection and inflammation, which can affect kidney function.
Choice C reason: Frequent bowel movements are not characteristic of peritonitis. The inflammation in the peritoneal cavity often leads to bowel paralysis, resulting in decreased bowel movements rather than increased frequency.
Choice D reason: A rigid abdomen is a hallmark sign of peritonitis. The rigidity is due to the body's protective response to the severe inflammation in the peritoneal cavity, causing the abdominal muscles to tighten and become hard. This clinical sign, along with severe pain, can help healthcare providers diagnose peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Macaroni and cheese is high in fat due to the cheese content, which can exacerbate symptoms of cholecystitis. Patients with cholecystitis should avoid high-fat foods to prevent gallbladder irritation.
Choice B reason: Roast turkey, if prepared without added fats, is a lean protein option that is suitable for a cholecystitis diet. It provides necessary nutrients without the high fat content that could trigger symptoms.
Choice C reason: Ice cream is high in fat and sugar, making it unsuitable for someone with cholecystitis. High-fat foods can lead to increased bile production and gallbladder contractions, causing pain and discomfort.
Choice D reason: Creamed chicken typically contains high amounts of fat from cream, which should be avoided by cholecystitis patients to prevent aggravating their condition.
Correct Answer is D
Explanation
Choice A reason: Securing the drain to the client's bed sheet is not appropriate as it does not ensure the drain is properly secured and could lead to accidental dislodgement.
Choice B reason: Measuring the drainage every hour for the first 8 hours is not standard practice. Usually, drainage measurement frequency is less frequent unless there are specific clinical concerns.
Choice C reason: Removing the JP drain should be done according to medical orders, and typically the nurse would not make the decision independently. The JP drain is usually removed when the output decreases to a minimal level and the surgeon orders its removal.
Choice D reason: Expelling the air from the JP bulb after emptying is the correct action to re-establish suction, which is necessary for the drain to function effectively.
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