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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Offering cups of fruit juices at frequent intervals is not recommended immediately postoperatively due to the risk of nausea and vomiting. The client should start with clear liquids and gradually progress.
Choice B rationale
Irrigating and repositioning the nasogastric tube frequently is not recommended as it can cause discomfort and dislodge the tube. Proper fixation and periodic checking are preferred.
Choice C rationale
Reminding the client that PCA use may slow the return of bowel function is not accurate. While opioids can slow bowel motility, PCA use is for pain management and should be monitored, not discouraged.
Choice D rationale
Having the client splint the surgical site while deep breathing and coughing helps prevent atelectasis and promotes lung expansion. It also reduces pain and protects the surgical incision during respiratory exercises. .
Correct Answer is ["688"]
Explanation
Step 1:
Calculate the duration in minutes from 1400 to 1930. 1930 - 1400 = 5 hours 30 minutes = 330 minutes
Step 2:
Determine the infusion rate per hour. 125 mL/hour
Step 3:
Calculate the total volume infused. (125 mL/hour) × (330 minutes ÷ 60 minutes/hour) = (125 mL/hour) × (5.5 hours) = 687.5 mL Rounded to the nearest whole number = 688 mL.
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