A nurse is assessing a patient who has peritonitis.
Which of the following findings should the nurse expect?
Rigid abdomen.
Increased urinary output.
Frequent bowel movements.
Hyperactive bowel sounds.
The Correct Answer is A
Choice A rationale
A rigid abdomen is a classic finding in peritonitis, an inflammation of the peritoneum. The inflammation causes the abdominal muscles to become tense and board-like as a protective mechanism. This rigidity is often accompanied by severe abdominal pain that is exacerbated by movement or palpation.
Choice B rationale
Increased urinary output is not a typical finding in peritonitis. In fact, due to fluid shifts and potential dehydration from the inflammatory process and decreased oral intake, urinary output may be decreased. Normal adult urinary output is generally considered to be at least 0.5 mL/kg/hour.
Choice C rationale
Frequent bowel movements are not characteristic of peritonitis. Peritonitis often leads to decreased bowel motility and potentially ileus due to the inflammation affecting the gastrointestinal tract. Bowel sounds may be diminished or absent rather than frequent.
Choice D rationale
Hyperactive bowel sounds are not typically associated with peritonitis. Initially, bowel sounds might be present, but as the inflammation progresses and ileus develops, bowel sounds usually become hypoactive or absent. Hyperactive bowel sounds are more commonly associated with early bowel obstruction or gastroenteritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cabbage contains some calcium, but its bioavailability is lower compared to other sources due to the presence of oxalates, which can bind to calcium and inhibit its absorption in the small intestine. While vegetables are important for overall health, cabbage is not a primary food source recommended for significantly increasing calcium levels.
Choice B rationale
Carrots are a good source of beta-carotene and fiber but are not particularly high in calcium content. Their primary nutritional benefits lie in providing vitamin A precursors and supporting digestive health. Therefore, increasing carrot intake would not significantly impact calcium levels.
Choice C rationale
Potatoes contain minimal amounts of calcium. They are primarily a source of carbohydrates, potassium, and vitamin C. While part of a balanced diet, they are not a recommended food for specifically increasing calcium intake to prevent or manage osteoporosis.
Choice D rationale
Broccoli is a good source of non-dairy calcium, and its bioavailability is relatively high. Additionally, broccoli provides other essential nutrients like vitamin K, which plays a role in bone health. Increasing the consumption of cruciferous vegetables like broccoli can contribute to improved calcium intake and support bone density.
Correct Answer is A
Explanation
Choice A rationale
Basal cell carcinoma is the most common type of skin cancer and often presents as a raised, flesh-colored or pearly white lesion with rolled borders and sometimes visible blood vessels (telangiectasia). Its slow growth and characteristic appearance align with the description provided.
Choice B rationale
Malignant melanoma is a more aggressive form of skin cancer that typically appears as an asymmetrical mole with irregular borders, uneven color (often shades of black, brown, red, white, or blue), and a diameter greater than 6 mm. It is less likely to present as a raised, flesh-colored lesion with pearly borders.
Choice C rationale
Actinic keratosis is a precancerous skin condition characterized by rough, scaly patches that develop on sun-exposed areas. These lesions are typically flat or slightly raised and can be red, tan, or flesh-colored. The description of pearly white borders does not typically fit actinic keratosis.
Choice D rationale
Squamous cell carcinoma is the second most common type of skin cancer and can appear as a firm, red nodule or a flat lesion with a scaly or crusted surface. While it can vary in appearance, the description of pearly white borders is more characteristic of basal cell carcinoma.
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