The nurse suspects that the client hospitalized with severe ulcerative colitis, may be developing the complication of toxic megacolon. Which assessment finding supports these suspicions?

Tenesmus.

Hyperactive bowel sounds.

An enlarging abdominal girth.

Anal fissures.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Tenesmus is a frequent urge to defecate, common in ulcerative colitis but not indicative of toxic megacolon. It results from inflammation and irritation of the rectal and colonic mucosa, causing discomfort and straining during bowel movements.

Choice B rationale

Hyperactive bowel sounds are associated with increased gastrointestinal activity, often seen in diarrheal states and early mechanical bowel obstruction but not typically linked to toxic megacolon. Toxic megacolon often presents with reduced or absent bowel sounds due to colonic paralysis.

Choice C rationale

An enlarging abdominal girth indicates distension, a significant sign of toxic megacolon. This condition involves extreme dilation of the colon, which can lead to severe abdominal distension due to trapped gas and stool. This can be life-threatening if not treated promptly.

Choice D rationale

Anal fissures are tears in the anal canal, common in chronic constipation or Crohn’s disease, not typically a sign of toxic megacolon. They cause pain and bleeding during bowel movements but do not indicate toxic megacolon.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Flush with 15-30 mL sterile water after each medication. This ensures the tube remains clear and free from blockages, facilitating effective medication administration and nutrient delivery.

Choice B rationale

Crush each immediate-release tablet and mix it in 15-30 mL sterile water. This practice ensures the medication is properly mixed and can be safely administered through the gastrostomy tube without clogging.

Choice C rationale

Add medications directly to the tube feeding formula. Directly adding medications to the feeding formula can result in interactions that reduce drug efficacy and potentially cause adverse effects.

Choice D rationale

Use liquid medications when available. Liquid forms are more easily administered through gastrostomy tubes, reducing the risk of clogs and ensuring better absorption.

Choice E rationale

Mix all medications, dilute with water and give them together. Mixing medications can lead to potential drug interactions, compromising their effectiveness and safety. It is better to administer them individually to avoid this risk. .

A. Most nights I sleep in the family room recliner because I get short of breath lying flat. B. I have been waking up at night sweating and wet all over. C. Lately, I wake up at night with a burning feeling in my chest. D. I have been experiencing headaches immediately after eating. E. Immediately after eating I feel sleepy and want to go to bed.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Shortness of breath while lying flat, known as orthopnea, can indicate worsening heart failure or other serious cardiac conditions. This symptom may suggest fluid buildup in the lungs due to inadequate heart function, requiring immediate medical evaluation.

Choice B rationale

Night sweats and excessive sweating can be associated with cardiac issues such as myocardial infarction or heart failure. These symptoms can indicate that the heart is not effectively pumping blood, leading to increased stress on the body.

Choice C rationale

Burning chest pain at night can be indicative of angina or even a myocardial infarction. Angina often worsens at night due to changes in heart rate and blood pressure during sleep. This symptom warrants prompt cardiac assessment to rule out severe cardiac events.

Choice D rationale

Headaches after eating are not typically associated with cardiac conditions. This symptom is more likely related to gastrointestinal or metabolic issues rather than cardiac problems.

Choice E rationale

Feeling sleepy after eating is usually due to normal postprandial somnolence and is not directly related to cardiac issues. This symptom does not require urgent cardiac evaluation.

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The nurse suspects that the client hospitalized with severe ulcerative colitis, may be developing the complication of toxic megacolon. Which assessment finding supports these suspicions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering medications to a client receiving tube feedings through a gastrostomy tube. The correct procedure for administration is to: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is ["A","B","C"]

Explanation

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