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 D

Explanation

D. In paralytic ileus, there is a lack of bowel motility, resulting in absent or diminished bowel sounds on auscultation and absent passage of flatus. The bowel sounds may be hypoactive or completely absent due to the lack of peristalsis. Additionally, the client may experience abdominal distention and discomfort due to the accumulation of gas and fluid in the intestines.
A. Pencil-thin stools are more commonly associated with conditions such as colorectal cancer or rectal strictures. In paralytic ileus, where there is a lack of bowel motility, the stools are typically absent rather than thin.
B. Fecal-smelling breath is not a typical finding in paralytic ileus. While it may occur in conditions associated with severe constipation or bowel obstruction, it is not specific to paralytic ileus.
C. Passage of mucus and blood in stools is not a characteristic finding of paralytic ileus. It is more commonly associated with conditions such as inflammatory bowel disease or colorectal cancer.

A. 5 pounds in one week. B. 1 pound in one week. C. 10 pounds in one month. D. 3 pounds in one week.

Correct Answer is B

Explanation

B. Losing 1 pound in one week is generally considered a safe and sustainable rate of weight loss for many individuals. It is recommended by health professionals as a realistic and achievable goal for healthy weight loss.
A. Losing 5 pounds in one week would be considered too rapid and potentially unhealthy weight loss. Rapid weight loss can lead to various health issues, including nutritional deficiencies, muscle loss, and a higher likelihood of regaining the weight later on
C. Losing 10 pounds in one month would also be considered too rapid and potentially unhealthy weight loss, especially if sustained over a longer period.
D. Losing 3 pounds in one week may be achievable for some individuals, but it is generally considered more rapid than the recommended rate of 1 pound per week.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with a paralytic ileus. What would be an expected assessment finding?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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