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 ["B","C","D"]
Explanation
Choice A rationale
A client who is ambulatory following a cardiac catheterization 4 hours ago has increased mobility, which reduces the risk of prolonged pressure on bony prominences. The short duration post-procedure and ability to ambulate make this client less susceptible to pressure ulcer development.
Choice B rationale
Postoperative delirium can lead to decreased mobility, increased agitation and friction against surfaces, and impaired ability to communicate discomfort or reposition themselves. These factors significantly increase the risk of prolonged pressure and subsequent pressure ulcer formation.
Choice C rationale
Protein-calorie malnutrition results in decreased subcutaneous tissue and muscle mass, which normally provide cushioning over bony prominences. Poor nutritional status also impairs tissue repair and increases skin fragility, making the client highly susceptible to pressure ulcer development.
Choice D rationale
Right-sided heart failure can cause fluid overload and peripheral edema, particularly in the lower extremities. This edema increases tissue fragility and reduces blood flow to the skin, making it more susceptible to breakdown and pressure ulcer formation, especially in areas with bony prominences like heels and ankles.
Choice E rationale
While hyperglycemia in type 1 diabetes mellitus can impair wound healing and increase the risk of infection if a pressure ulcer develops, it is not a direct primary risk factor for the initial development of pressure ulcers. Immobility, malnutrition, and edema are more direct contributors to skin breakdown due to pressure.
Correct Answer is D
Explanation
Choice A rationale
Avoiding snacking between meals can actually worsen GERD symptoms for some individuals by allowing the stomach to become completely empty, which can then lead to increased acid production when the next meal is consumed. Smaller, more frequent meals are often recommended to maintain a more consistent level of gastric contents and reduce acid reflux.
Choice B rationale
Limiting foods high in fiber is generally not recommended for managing GERD. Fiber helps with gastric emptying and can prevent constipation, which can indirectly increase intra-abdominal pressure and potentially worsen reflux. A balanced diet with adequate fiber is usually encouraged.
Choice C rationale
Elevating the head of the bed by 6 to 8 inches, not 18 inches, is a recommended strategy to manage GERD. Gravity helps to keep stomach acid down in the stomach. An elevation of 18 inches might be too steep and uncomfortable for sleeping, potentially leading to other issues.
Choice D rationale
Avoiding eating 2 to 3 hours before bedtime is a crucial recommendation for managing GERD. Lying down shortly after eating can facilitate the backflow of stomach acid into the esophagus because gravity no longer assists in keeping the acid in the stomach. Allowing time for some gastric emptying before lying down can significantly reduce nighttime reflux symptoms. .
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