A nurse is assessing a patient who has peritonitis.
Which of the following findings should the nurse expect?
Hyperactive bowel sounds.
Increased urinary output.
Rigid abdomen.
Frequent bowel movements.
The Correct Answer is C
Choice A rationale
Hyperactive bowel sounds would not be expected in a patient with peritonitis. Peritonitis is an inflammation of the peritoneum, which often results in paralytic ileus due to the inflammatory response and chemical irritation. This leads to decreased or absent bowel motility, and therefore, the nurse would expect to find hypoactive or absent bowel sounds upon auscultation.
Choice B rationale
Increased urinary output is an unlikely finding in a patient with peritonitis. The inflammatory response and fluid shifts into the third space can lead to hypovolemia, decreased renal perfusion, and reduced urine output. A patient with peritonitis is more likely to experience oliguria or even anuria as a result of the body's compensatory mechanisms to maintain circulating blood volume.
Choice C rationale
Rigid abdomen is a classic and significant finding in a patient with peritonitis. This is due to the involuntary guarding of the abdominal muscles, which contract as a protective response to the irritation of the parietal peritoneum. This board-like rigidity is a critical indicator of severe abdominal inflammation and requires immediate medical attention.
Choice D rationale
Frequent bowel movements are not expected. Peritonitis causes decreased or absent bowel motility due to paralytic ileus. This condition, combined with the pain and inflammation, would likely lead to constipation or the absence of bowel sounds, rather than frequent bowel movements, which are more characteristic of conditions like gastroenteritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Urinary retention is a common symptom of various genitourinary conditions in older adults, such as benign prostatic hyperplasia or medication side effects. While it can occur with a UTI, it is not a specific or unique manifestation of a UTI in this population, as it is also a symptom of other conditions.
Choice B rationale
Incontinence can be a symptom of a UTI, particularly in older adults who may have weakened bladder control. However, new-onset incontinence can also be related to other issues such as weakened pelvic floor muscles, medications, or neurological conditions, making it a non-specific finding.
Choice C rationale
Confusion or a sudden change in mental status is a hallmark and often the only sign of a urinary tract infection in older adults. Due to an altered immune response and less localized inflammatory response, they may not exhibit classic symptoms like dysuria or fever, making confusion a specific and critical indicator of infection.
Choice D rationale
Low back pain can be a symptom of a urinary tract infection, particularly if the infection has ascended to the kidneys (pyelonephritis). However, low back pain is a very common complaint in older adults due to musculoskeletal issues, arthritis, and other conditions, which makes it a non-specific and unreliable indicator.
Correct Answer is B
Explanation
Choice A rationale
The onset of action for NPH insulin is typically 1.5 to 4 hours after administration. A peak at 8 a.m. would be too early, as it is only one hour after the injection time of 7 a.m. This timing would be more characteristic of a rapid-acting insulin such as lispro (Humalog) or aspart (Novolog).
Choice B rationale
NPH insulin is an intermediate-acting insulin. Its pharmacokinetics are characterized by a typical onset of 1.5 to 4 hours, a peak effect of 4 to 12 hours, and a duration of 14 to 24 hours. Given a 7 a.m. administration, the peak benefit is expected within the 4-12 hour window, making 10 a.m. a plausible time for the peak.
Choice C rationale
A peak at 5 p.m. would represent 10 hours post-administration, which falls within the typical 4-12 hour peak range for NPH insulin. However, 10 a.m. (3 hours post-administration) is also within the peak window and a more common early peak time. Both B and C are scientifically plausible, but 10 a.m. is a more representative average early peak.
Choice D rationale
A peak at 11: p.m. would be 16.5 hours after the 7 a.m. administration. This time is well outside the typical 4 to 12-hour peak range for NPH insulin. By 11: p.m., the insulin's effect would likely be waning or nearing the end of its duration of action.
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