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 A
Explanation
Choice A reason: Colonoscopy is the most accurate diagnostic test for diverticulosis, which is the presence of pouches or sacs in the wall of the colon. It allows the direct visualization of the colon and the identification of any diverticula, polyps, or tumors. The nurse should prepare the client to undergo bowel preparation, sedation, and monitoring before and after the procedure.
Choice B reason: Magnetic resonance imaging (MRI) is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses a magnetic field and radio waves to create detailed images of the internal organs and tissues. It is more commonly used for brain, spine, joint, or soft tissue disorders.
Choice C reason: Abdominal ultrasound is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses sound waves to create images of the abdominal organs and structures. It is more commonly used for liver, gallbladder, kidney, or spleen disorders.
Choice D reason: Computed tomography (CT) scan with contrast is not a diagnostic test for diverticulosis. It is an invasive imaging technique that uses x-rays and a contrast dye to create cross-sectional images of the body. It is more commonly used for detecting tumors, abscesses, or bleeding. It is also used for diagnosing diverticulitis, which is the inflammation or infection of the diverticula.
Correct Answer is D
Explanation
Choice A reason: Half-normal saline solution is a hypotonic solution, which means it has a lower concentration of solutes than the blood plasma. It can cause fluid to shift from the blood vessels into the cells, leading to cellular swelling and edema.
Choice B reason: 10% dextrose in water is a hypertonic solution, which means it has a higher concentration of solutes than the blood plasma. It can cause fluid to shift from the cells into the blood vessels, leading to cellular shrinkage and dehydration.
Choice C reason: 5% dextrose and half-normal saline solution is a hypertonic solution, which has the same effects as choice B. The dextrose increases the osmolarity of the solution, while the half-normal saline provides some electrolytes.
Choice D reason: Lactated Ringer's solution is an isotonic solution, which means it has the same concentration of solutes as the blood plasma. It maintains fluid balance and provides electrolytes such as sodium, potassium, calcium, and lactate. It is commonly used for fluid resuscitation, dehydration, and acidosis.
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