A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of extreme abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?
Call the primary provider and report that the client may be obstructed.
Position the client supine and insert an NG tube.
Administer a fleet enema as prescribed and remain with the client.
Contact the primary provider promptly and report these signs of perforation.
The Correct Answer is D
Choice A reason: This is not the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.
Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.
Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.
Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sliced ham with green salad is not a good choice for a client who has diverticulitis. Diverticulitis is a condition where small pouches in the colon become inflamed or infected. The client should avoid foods that are high in fat, such as ham, or that contain seeds, nuts, or skins, such as green salad, as they can irritate the colon and worsen the symptoms.
Choice B reason: Pork tenderloin with green peas is not a suitable choice for a client who has diverticulitis. Pork tenderloin is a high-fat food that can increase the inflammation and pain in the colon. Green peas are also a source of fiber that can be hard to digest and can cause gas and bloating.
Choice C reason: Turkey sandwich with celery sticks is not an appropriate choice for a client who has diverticulitis. Turkey sandwich may contain mayonnaise, cheese, or other ingredients that are high in fat and can aggravate the condition. Celery sticks are high in fiber and have strings that can get trapped in the pouches and cause infection.
Choice D reason: Grilled chicken breast with white bread is the best choice for a client who has diverticulitis. Grilled chicken breast is a lean protein that can help the client heal and prevent malnutrition. White bread is a low-fiber food that can be easily digested and does not irritate the colon.
Correct Answer is B
Explanation
Choice A reason: Calling the doctor for more antiemetic medication is not the best intervention for the nurse to facilitate. Antiemetics are drugs that prevent or reduce nausea and vomiting, but they may have side effects such as drowsiness, dry mouth, or constipation. The nurse should first try non-pharmacological measures to relieve the patient's nausea, such as giving small sips of water, providing a cool and quiet environment, or using aromatherapy.
Choice B reason: Giving the patient small sips of tepid water is the best intervention for the nurse to facilitate. Water can help hydrate the patient and dilute any stomach acid that may cause irritation. Tepid water is water that is slightly warm, which can be more soothing than cold or hot water. Small sips can prevent the patient from swallowing too much air, which can worsen nausea and vomiting.
Choice C reason: Helping the patient lay supine is not a good intervention for the nurse to facilitate. Supine means lying flat on the back, which can increase the risk of aspiration, or inhaling food or fluids into the lungs. Aspiration can cause pneumonia, a serious lung infection. The nurse should help the patient lay on their side, with their head elevated, to prevent aspiration and reduce pressure on the stomach.
Choice D reason: Showing the patient how to use the patient-controlled analgesia is not a relevant intervention for the nurse to facilitate. Patient-controlled analgesia is a system that allows the patient to self-administer pain medication through an IV pump. It has nothing to do with nausea and vomiting, and may even cause them as side effects. The nurse should monitor the patient's pain level and adjust the analgesia settings as needed, but not as a way to treat nausea.
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