A client with peritonitis experiences abdominal distension and decreased bowel sounds on auscultation. The nurse recognizes these findings as suggestive of:
Hypovolemic shock
Paralytic ileus
Intestinal obstruction
Urinary retention
The Correct Answer is B
Choice A reason:
Hypovolemic shock involves severe blood loss or fluid depletion and may present with signs of hypotension and tachycardia but is not directly related to the findings described.
Choice B reason:
Paralytic ileus is a lack of bowel motility that causes abdominal distension and decreased bowel sounds, and it is a common complication of peritonitis.
Choice C reason:
Intestinal obstruction involves a blockage of the intestines and may present with abdominal distension and altered bowel sounds, but it is not directly related to peritonitis in this context.
Choice D reason:
Urinary retention involves the inability to empty the bladder fully and is not related to the findings described in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Hypovolemic shock involves severe blood loss or fluid depletion and may present with signs of hypotension and tachycardia but is not directly related to the findings described.
Choice B reason:
Paralytic ileus is a lack of bowel motility that causes abdominal distension and decreased bowel sounds, and it is a common complication of peritonitis.
Choice C reason:
Intestinal obstruction involves a blockage of the intestines and may present with abdominal distension and altered bowel sounds, but it is not directly related to peritonitis in this context.
Choice D reason:
Urinary retention involves the inability to empty the bladder fully and is not related to the findings described in the scenario.
Correct Answer is D
Explanation
Choice A reason:
Rebound tenderness refers to increased pain upon release of pressure during palpation and is not related to the finding of a rigid, board-like abdomen.
Choice B reason:
Paralytic ileus refers to a condition in which the intestines stop functioning, causing a lack of bowel sounds and distension, but it is not directly related to the rigid abdomen finding.
Choice C reason:
Abdominal compartment syndrome may cause abdominal distension and increased intra-abdominal pressure, but it does not necessarily result in a rigid, board-like abdomen.
Choice D reason:
The finding of a rigid, board-like abdomen upon palpation is known as guarding, which is a protective response of the abdominal muscles in peritonitis to minimize movement and protect the inflamed peritoneum.
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