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 D
Explanation
Choice A reason: Adjusting the rate of the infusion or catheter drainage without first identifying the cause of the lack of drainage can be ineffective. It is essential to determine whether there is a physical obstruction before making rate adjustments.
Choice B reason: Irrigating the catheter might be necessary if there is a blockage, but it is not the first step. Checking the tubing for kinks should be done first to identify and correct any simple mechanical obstructions.
Choice C reason: Notifying the provider is important if the issue persists, but the nurse should first assess and try to resolve the problem by checking for any obvious causes like kinks in the tubing. Immediate provider notification is not the first action.
Choice D reason: Checking the tubing for kinks is the first and most logical step. Kinks in the catheter tubing can easily obstruct urine flow, and this simple assessment can quickly identify and resolve the issue, restoring proper drainage.
Correct Answer is C
Explanation
Choice A reason: A bladder infection can cause various symptoms, but blood-tinged urine is less specific to it.
Choice B reason: Dehydration typically leads to concentrated urine, not blood-tinged urine.
Choice C reason: Prostate enlargement (benign prostatic hyperplasia) can cause blood-tinged urine due to irritation and pressure on the urethra.
Choice D reason: Pernicious anemia affects red blood cell production but is not directly related to the presence of blood in the urine.
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