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
Decreased hemoglobin is typically associated with chronic inflammation in rheumatoid arthritis, but it is not considered an early manifestation. Anemia of chronic disease develops over time due to the effects of inflammatory cytokines on iron metabolism and erythropoiesis. Normal hemoglobin ranges for females are 12 to 15.5 g/dL and for males are 13.5 to 17.5 g/dL.
Choice B rationale
Temporomandibular joint pain can occur in rheumatoid arthritis, but it is not a specific or consistent early manifestation. While RA can affect various joints, the small joints of the hands and feet are more commonly involved in the early stages. Pain in the TMJ can also be related to other conditions.
Choice C rationale
Fatigue is a common systemic symptom in rheumatoid arthritis and can occur early in the disease process. However, fatigue is also a nonspecific symptom that can be present in many other conditions, making it less definitive as an early diagnostic indicator compared to joint involvement.
Choice D rationale
Symmetric joint swelling of the fingers, particularly the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, is a hallmark early manifestation of rheumatoid arthritis. The inflammation causes synovial thickening and effusion, leading to palpable swelling that affects the same joints on both sides of the body.
Correct Answer is A
Explanation
Choice A rationale
Basal cell carcinoma, the most common type of skin cancer, often presents as a raised, flesh-colored or pearly white papule or nodule with rolled, pearly borders and telangiectasia (visible small blood vessels). The description of the 1-cm raised, flesh-colored lesion with pearly white borders aligns with the typical appearance of basal cell carcinoma.
Choice B rationale
Malignant melanoma is characterized by its irregular shape, asymmetrical borders, uneven color (often with shades of black, brown, red, white, or blue), and diameter greater than 6 mm. It can arise from existing moles or appear as a new pigmented lesion. The described lesion does not fit this profile.
Choice C rationale
Actinic keratosis is a precancerous skin condition that appears as rough, scaly patches on sun-exposed areas. These lesions are typically flat or slightly raised and can be skin-colored, reddish-brown, or have a whitish scale. The description of a raised lesion with pearly borders is inconsistent with actinic keratosis.
Choice D rationale
Squamous cell carcinoma often presents as a firm, red nodule or a flat lesion with a scaly, crusted surface. It can also appear as a non-healing ulcer. While it can occur on the chest, the pearly white borders are more characteristic of basal cell carcinoma.
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