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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. TPN does provide all of the client's nutritional needs, including carbohydrates, proteins, fats, vitamins, minerals, and electrolytes, in a hypertonic solution. The hypertonicity of the solution is necessary to prevent fluid overload and ensure compatibility with the vasculature. The hypertonic solution allows for higher nutrient concentrations to be delivered without exceeding vascular capacity.
A. TPN is indicated for clients who are unable to tolerate enteral nutrition (feeding through the gastrointestinal tract) or have impaired absorption, digestion, or utilization of nutrients despite having active GI function.
B. TPN may be used temporarily after a surgical procedure if the client is unable to tolerate oral or enteral feeding or if enteral nutrition is contraindicated due to the surgical site or condition. However, TPN is not limited to short-term use after surgery and may be required for an extended period in clients with chronic conditions or prolonged inability to tolerate enteral nutrition.
D. TPN may be used in some cases after a laparotomy for a bowel obstruction, particularly if enteral nutrition is contraindicated or if the client is unable to tolerate oral intake. However, TPN is not primarily used to prevent complications after surgery but rather to provide nutritional support when enteral feeding is not feasible or sufficient.
Correct Answer is ["A","B","D"]
Explanation
A. Daily weighing can help individuals monitor their progress and stay accountable for their weight loss goals. However, it's essential to emphasize that weight can fluctuate due to various factors such as hydration, digestion, and muscle mass changes, so the focus should be on overall trends rather than daily fluctuations.
B. Joining a support group can provide individuals with encouragement, motivation, and accountability during their weight loss journey. It allows them to connect with others who are facing similar challenges and share strategies for success.
D. Keeping a food diary or journal can be a valuable tool for promoting awareness of eating habits, tracking calorie intake, and identifying patterns or triggers for overeating. It helps individuals make informed choices about their diet and can contribute to successful weight loss by promoting accountability and mindfulness.
C. Use large, yellow plates is not typically included in successful weight loss strategies. Plate size and color may have minimal impact on food intake compared to factors such as portion control, food choices, and mindful eating practices.
E. Eating quickly and leaving the table can lead to overeating because it doesn't allow time for the body to register fullness signals.
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