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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Emptying the appliance daily at bedtime is not frequent enough to prevent leakage and ensure comfort, especially if the bag fills up during the day or night.
Choice B reason: Emptying the appliance twice a day may not be sufficient, depending on the amount of urine output. It could lead to overfilling and leakage.
Choice C reason: Waiting until the bag is full can increase the risk of leakage and discomfort. It is essential to empty the bag before it gets too full.
Choice D reason: Emptying the appliance when it is 2/3 full is the recommended practice. This prevents overfilling, reduces the risk of leakage, and ensures the client's comfort and hygiene.

A. The client requires the use of a colostomy bag. B. The client has a loss of appetite following surgery. C. The client has absent bowel sounds in the lower abdominal quadrants. D. The client is experiencing mild pain at the surgical site when sitting up.

Correct Answer is C

Explanation

Choice A reason: The use of a colostomy bag is expected following surgery for colorectal cancer that involves the creation of a stoma. This does not indicate a complication.
Choice B reason: A loss of appetite is common after major surgery and can be managed with nutritional support and gradual reintroduction of food.
Choice C reason: Absent bowel sounds in the lower abdominal quadrants could indicate a paralytic ileus or bowel obstruction, which are serious complications requiring immediate intervention to prevent further issues such as bowel ischemia.
Choice D reason: Mild pain at the surgical site is expected and can be managed with prescribed pain medications. It does not indicate a serious complication.

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A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

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