The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?
Administer an antipyretic
Notify the healthcare provider
Prepare to administer an enema.
Continue to monitor the client closely
The Correct Answer is B
peritonitis are present. Treating the underlying cause (perforation) is more urgent than lowering the fever.
B. Notify the healthcare provider: A hard, rigid abdomen with fever indicates possible perforation and peritonitis, which is a medical emergency. The provider must be notified immediately for urgent intervention.
C. Prepare to administer an enema: Enemas are contraindicated in acute diverticulitis due to the risk of perforation.
D. Continue to monitor the client closely: While continued monitoring is always necessary, immediate action (calling the provider) is critical when signs of peritonitis are present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["45"]
Explanation
30g x 10g ×15ml=45ml
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The client's ammonia level is critically elevated (250 mcg/dL), which can lead to altered mental status, confusion, and lethargy, consistent with hepatic encephalopathy. In cirrhosis, the liver loses its ability to detoxify ammonia, leading to its accumulation in the bloodstream. This excess ammonia crosses the blood-brain barrier, impairing neuronal function and causing hepatic encephalopathy.
Incorrect answers:
DKA is characterized by high blood glucose (>250 mg/dL), metabolic acidosis, and ketonemia. This client has a moderate glucose elevation (148 mg/dL) but no signs of acidosis, Kussmaul respirations, or ketonuria.
Dehydration: While dehydration can contribute to mental status changes, severe hyperammonemia is a direct cause of hepatic encephalopathy. The client's crackles in the lungs and peripheral edema suggest fluid retention, not dehydration.
Acute kidney disease presents with rising creatinine levels, oliguria, and electrolyte imbalances. This client’s creatinine level is normal, ruling out acute kidney disease.
Malnutrition is characterized by low albumin, muscle wasting, and weight loss, but this client's elevated glucose is more likely due to diabetes mellitus rather than malnutrition.
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