A nurse is caring for a client with peritonitis and observes a rigid, board-like abdomen upon palpation. The nurse recognizes this finding as:
Rebound tenderness
Paralytic ileus
Abdominal compartment syndrome
Guarding
The Correct Answer is D
Choice A reason:
Rebound tenderness refers to increased pain upon release of pressure during palpation and is not related to the finding of a rigid, board-like abdomen.
Choice B reason:
Paralytic ileus refers to a condition in which the intestines stop functioning, causing a lack of bowel sounds and distension, but it is not directly related to the rigid abdomen finding.
Choice C reason:
Abdominal compartment syndrome may cause abdominal distension and increased intra-abdominal pressure, but it does not necessarily result in a rigid, board-like abdomen.
Choice D reason:
The finding of a rigid, board-like abdomen upon palpation is known as guarding, which is a protective response of the abdominal muscles in peritonitis to minimize movement and protect the inflamed peritoneum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Continuous gastric suction is not primarily intended to prevent aspiration pneumonia, although it may indirectly help reduce the risk of aspiration in some cases.
Choice B reason:
Reducing intra-abdominal pressure is not the primary purpose of continuous gastric suction, although it may have some effect on the overall abdominal pressure.
Choice C reason:
Continuous gastric suction is not primarily intended to manage pain and discomfort in the client with peritonitis, although it may help alleviate some symptoms.
Choice D reason:
Promoting bowel rest is the main purpose of continuous gastric suction in the management of peritonitis. By reducing the workload of the gastrointestinal tract, the inflamed peritoneum can heal and recover more effectively.
Correct Answer is C
Explanation
Choice A reason:
Maintaining a low-fiber diet is not a standard recommendation for clients recovering from peritonitis.
Choice B reason:
Avoiding physical activity for two weeks is not necessary for all clients recovering from peritonitis, and individualized recommendations should be provided based on the client's condition and physician's instructions.
Choice C reason:
Taking prescribed antibiotics as directed is essential for clients recovering from peritonitis to complete the course of treatment and ensure the infection is fully eradicated.
Choice D reason:
Using a heating pad for abdominal pain relief may not be recommended for all clients recovering from peritonitis, as it may exacerbate inflammation or lead to complications. Individualized pain management strategies should be discussed with the healthcare provider.
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