A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?
Hyperactive bowel sounds
Increased urinary output
Frequent bowel movements
Rigid abdomen
The Correct Answer is D
Choice A reason: Hyperactive bowel sounds are not typically associated with peritonitis. Instead, peritonitis often leads to decreased or absent bowel sounds due to the inflammation and subsequent ileus (paralysis of the bowel), which slows down or halts peristalsis.
Choice B reason: Increased urinary output is not a common symptom of peritonitis. In fact, peritonitis can sometimes result in reduced urine output due to the body's response to infection and inflammation, which can affect kidney function.
Choice C reason: Frequent bowel movements are not characteristic of peritonitis. The inflammation in the peritoneal cavity often leads to bowel paralysis, resulting in decreased bowel movements rather than increased frequency.
Choice D reason: A rigid abdomen is a hallmark sign of peritonitis. The rigidity is due to the body's protective response to the severe inflammation in the peritoneal cavity, causing the abdominal muscles to tighten and become hard. This clinical sign, along with severe pain, can help healthcare providers diagnose peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wearing an external collection bag is typically associated with other types of urinary diversions, such as an ileal conduit, not a neobladder.
Choice B reason: A neobladder involves the creation of an internal pouch from a segment of the intestine that stores urine and allows for more natural urination, similar to the function of a natural bladder. This option provides the ability to void through the urethra.
Choice C reason: While some initial incontinence can occur after neobladder surgery, the goal is to eventually have voluntary control over urination with time and practice.
Choice D reason: Having a stoma located in the abdomen is characteristic of an ileal conduit or urostomy, not a neobladder. The neobladder is designed to avoid the need for an external stoma.
Correct Answer is C
Explanation
Choice A reason: The use of a colostomy bag is expected following surgery for colorectal cancer that involves the creation of a stoma. This does not indicate a complication.
Choice B reason: A loss of appetite is common after major surgery and can be managed with nutritional support and gradual reintroduction of food.
Choice C reason: Absent bowel sounds in the lower abdominal quadrants could indicate a paralytic ileus or bowel obstruction, which are serious complications requiring immediate intervention to prevent further issues such as bowel ischemia.
Choice D reason: Mild pain at the surgical site is expected and can be managed with prescribed pain medications. It does not indicate a serious complication.
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