The nurse is caring for an adolescent with a ruptured appendix. What assessment findings would support the diagnosis of peritonitis?

Hyperactive bowel sounds

Profuse diarrhea

A hard, rigid abdomen

Abdominal cramping

Answer and Explanation

The Correct Answer is C

A.   This finding is generally not associated with peritonitis. Instead, hyperactive bowel sounds may indicate early gastrointestinal irritation or obstruction. In the case of peritonitis, bowel sounds are often diminished or absent due to the inflammation and irritation of the peritoneum.
B.   Profuse diarrhea is not a typical sign of peritonitis. While gastrointestinal disturbances can occur, diarrhea is more commonly associated with infections or irritations of the intestines rather than with peritonitis itself. Peritonitis typically presents with symptoms related to abdominal rigidity and pain.
C.   A hard, rigid abdomen is a classic sign of peritonitis. It indicates involuntary guarding, which occurs as a response to inflammation and irritation of the peritoneum. The rigidity reflects the body's protective mechanism against pain and is a significant assessment finding.

D.   While abdominal cramping can occur in various gastrointestinal conditions, it is not a specific indicator of peritonitis. In cases of peritonitis, the pain is often more severe and localized rather than cramping. The patient may experience sharp, steady pain that worsens with movement.

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Correct Answer is D

Explanation

A. While using an incentive spirometer is important in promoting lung expansion and preventing respiratory complications, it is not directly related to the administration of acyclovir. This intervention is typically more relevant for patients at risk of respiratory issues.
B. A high-carbohydrate diet is not a specific recommendation related to acyclovir administration. While nutrition is important for overall health, this intervention does not address the key concerns associated with the use of acyclovir.
C. While activity levels may need to be monitored based on the patient's overall condition, limiting activity is not a primary concern with acyclovir. The medication itself does not usually require significant restrictions on physical activity unless the patient has other conditions that warrant it.
D. Acyclovir can be nephrotoxic, especially when given intravenously, and maintaining adequate hydration helps prevent kidney damage. Encouraging fluids ensures that the kidneys can effectively excrete the medication and reduces the risk of crystallization in the renal tubules.

A. The spouse washes their hands frequently with soap and water. B. The spouse drinks electrolyte solution. C. The spouse prepares lunch for the client. D. The spouse uses a separate tube of toothpaste.

Correct Answer is C

Explanation

A. Frequent handwashing is critical in preventing the spread of infections, especially when one person in the household is ill with gastroenteritis. This practice indicates good hygiene and care for the client.
B. Drinking an electrolyte solution can help the spouse stay hydrated, especially when experiencing frequent loose stools due to gastroenteritis. Staying hydrated is essential for recovery.
C. If the spouse is actively preparing food for the client while having gastroenteritis, there is a risk of contaminating the food, which could lead to the client becoming ill. The client may be more vulnerable to infections, particularly following a stroke, and it is crucial to prevent exposure to any pathogens.
D. This observation is a good practice as it helps prevent the spread of germs. Using separate personal items, like a toothbrush and toothpaste, can minimize the risk of transmitting infections.

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The nurse is caring for an adolescent with a ruptured appendix. What assessment findings would support the diagnosis of peritonitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is most critical during the administration of acyclovir?

Correct Answer is D

Explanation

The nurse makes a home care visit to a client with a diagnosis of right sided stroke. The client's spouse reports that she was recently diagnosed with gastroenteritis and is having frequent loose stools. The nurse is most concerned with which observation?

Correct Answer is C

Explanation

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