A client is being seen in the clinic for severe abdominal pain with nausea and vomiting. The nurse assesses the abdomen and notes an absence of bowel sounds and a very rigid abdomen. What would these assessment findings most likely indicate?
Ulcerative colitis.
Appendicitis.
Peritonitis.
Diverticulitis.
The Correct Answer is C
Peritonitis. The assessment findings of an absence of bowel sounds and a very rigid abdomen in a client with severe abdominal pain, nausea, and vomiting are indicative of peritonitis. Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. The inflammation can occur due to an infection or other causes, and it can cause abdominal pain, nausea, vomiting, and a rigid abdomen. An absence of bowel sounds is also a characteristic finding of peritonitis.
A is not the correct answer because ulcerative colitis is a chronic inflammatory bowel disease that causes inflammation and ulcers in the colon and rectum.
B is not the correct answer because appendicitis is inflammation of the appendix, which can cause right lower quadrant abdominal pain, nausea, vomiting, and fever.
D is not the correct answer because diverticulitis is inflammation of one or more diverticula, which are small pouches that can form in the colon. It can cause left lower quadrant abdominal pain, fever, diarrhea, or constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Cerebrospinal fluid is cloudy in nature. Cloudy cerebrospinal fluid is a sign of infection or inflammation in the central nervous system, and lumbar puncture can be used to obtain cerebrospinal fluid for diagnostic purposes. The nurse should report this finding immediately to the physician for further evaluation and management.
Choice A, client states a piercing feeling, is incorrect because a piercing feeling is common during the procedure due to the insertion of the needle into the subarachnoid space.
Choice B, physician maintains aseptic procedure, is incorrect because maintaining aseptic technique during the procedure is standard protocol to prevent infection.
Choice C, client states a pressure relief in the head, is incorrect because this is not a concerning finding during the procedure.
Correct Answer is A
Explanation
Palpate gently without repeated attempts. Palpating the thyroid gland can stimulate the release of thyroid hormone, which can result in a thyroid storm, a potentially life-threatening condition characterized by a rapid heart rate, fever, and high blood pressure. Therefore, the nurse should be careful not to overstimulate the thyroid gland.
Not palpating the thyroid and just listening for a bruit (B) is not a sufficient assessment of the thyroid gland. Palpating the gland firmly in order to feel it for enlargement (C) can be too stimulating and increase the risk of thyroid hormone release. Continuing to palpate the gland until it is felt for enlargement (D) is not necessary and may result in overstimulation of the gland.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today