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 ["A","B","D","E"]
Explanation
Pre-operative education is successful when the client states that there will be blood and mucus initially exiting the stoma, the stoma will shrink a bit over a period of weeks, the stoma should be beefy red, and drainage will begin approximately 24-48 hours following surgery. These statements indicate that the client has a good understanding of what to expect after surgery.
Option C, The stool will be of normal consistency and color, is not a correct answer as the stool from an ostomy is different from normal stool consistency and color.
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.
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