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 C

Explanation

Choice A reason: Mr. Dominic's pain has been controlled to a manageable level, and although he experienced elevated liver enzymes, there are no acute symptoms requiring immediate intervention. He has been able to sleep, indicating that his current condition is stable.
Choice B reason: Mr. Bradford, although experiencing discomfort and blood-tinged urine, is post-surgical, and his condition is stable with managed output. Ambulating is a positive sign post-surgery, indicating recovery. His condition needs monitoring but is not the most urgent.
Choice C reason: Mr. Jennings, who had a TURBT yesterday, is experiencing bladder spasms and high volume irrigation. The output is almost equivalent to the input, which is a positive sign, but bladder spasms can indicate irritation, infection, or a blockage that needs prompt assessment and intervention to prevent further complications.
Choice D reason: Ms. Griffiths presents a similar case to Mr. Dominic, with controlled pain and elevated liver enzymes. She is stable overnight, and her pain level is low after medication, indicating her condition is currently managed.

A. Epigastric-area pain that intensifies when the patient is lying down B. Right upper-quadrant pain radiating to the shoulder and scapula C. Right lower-quadrant pain with rebound tenderness D. Left-flank pain with intermittent exacerbations

Correct Answer is B

Explanation

Choice A reason: Epigastric-area pain that intensifies when lying down is more commonly associated with conditions like gastroesophageal reflux disease (GERD) or pancreatitis, rather than cholecystitis.
Choice B reason: Right upper-quadrant pain radiating to the shoulder and scapula is a classic symptom of cholecystitis. This pain is due to inflammation of the gallbladder, often aggravated by fatty meals, and may radiate to the back and shoulder.
Choice C reason: Right lower-quadrant pain with rebound tenderness is typically associated with appendicitis rather than cholecystitis. Cholecystitis primarily affects the right upper quadrant.
Choice D reason: Left-flank pain with intermittent exacerbations is not characteristic of cholecystitis. It might indicate conditions related to the left kidney or other left-sided abdominal issues.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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