The nurse suspects that the client, hospitalized with severe ulcerative colitis, is experiencing the complication of toxic megacolon. Which assessment finding would support this suspicion?

Increased passage of gas and stool

Enlarging abdominal girth

Hyperactive bowel sounds

Afebrile

Answer and Explanation

The Correct Answer is B

B. Toxic megacolon is characterized by severe colonic dilation, leading to a significant increase in abdominal girth. As the colon becomes distended, it can cause visible abdominal swelling and bloating, which may be accompanied by tenderness upon palpation.
A. In the context of toxic megacolon, there may be a reduction or cessation of bowel movements due to colonic dilation and paralysis.
C. In toxic megacolon, bowel sounds may initially be hyperactive due to increased peristalsis as the colon attempts to overcome the obstruction. However, as the condition progresses, bowel sounds may diminish or become absent due to colonic dilation and paralysis.
D. While fever can be present in toxic megacolon due to the underlying inflammatory process, it is not universally seen in all cases.

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Correct Answer is A

Explanation

A. Before taking further action, the nurse should investigate whether there have been any changes in the client's diet, exercise routine, or lifestyle that may have contributed to the plateau in weight loss. Understanding any modifications made by the client can provide valuable insights into potential factors affecting their weight loss progress.
B. Bariatric surgery is a significant decision that requires careful consideration and evaluation of various factors. It is not appropriate to jump to this option without first exploring other potential reasons for the lack of weight loss.
C. While it's essential to review diet and exercise guidelines periodically to ensure the client is following appropriate recommendations, this option may not address the underlying cause of the recent lack of weight loss.
D. Regular weight monitoring is an important component of weight management and can provide valuable information about the client's progress. However, instructing the client to record weight weekly alone may not address the underlying reason for the lack of weight loss.

A. Chronic pain B. Impaired urinary elimination C. Risk for bleeding D. Risk for urinary tract injury

Correct Answer is B

Explanation

B. Impaired urinary elimination: This is the priority problem for a client diagnosed with BPH. BPH commonly obstructs the flow of urine out of the bladder, leading to symptoms such as urinary hesitancy, weak urinary stream, incomplete emptying, and urinary retention. Addressing impaired urinary elimination is crucial to prevent complications such as urinary retention, urinary tract infections, and kidney damage.

A. While BPH can cause symptoms such as urinary hesitancy, frequency, urgency, and incomplete emptying, chronic pain is not typically a primary symptom of BPH itself. However, complications of BPH, such as urinary retention or urinary tract infections, may cause discomfort or pain. Addressing pain related to complications of BPH is important but may not be the priority in all cases.
C. While BPH itself does not typically increase the risk of bleeding, procedures used to diagnose or treat BPH, such as transurethral resection of the prostate (TURP), may carry a risk of bleeding. However, this risk is usually managed intraoperatively and postoperatively by healthcare providers. In the absence of specific interventions or procedures with bleeding risks, addressing bleeding may not be the priority for a client with BPH.
D. Urinary tract injury, particularly during surgical procedures to treat BPH, is a potential complication. However, it may not be the priority problem in the absence of planned interventions or procedures.

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The nurse suspects that the client, hospitalized with severe ulcerative colitis, is experiencing the complication of toxic megacolon. Which assessment finding would support this suspicion?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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