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 D
Explanation
Choice A reason: Spironolactone is a potassium-sparing diuretic, so it is more likely to cause elevated potassium levels rather than decreased levels.
Choice B reason: Chloride levels are not typically affected in a predictable pattern with the use of spironolactone or in liver failure with ascites.
Choice C reason: Phosphate levels are not commonly altered by spironolactone or in ascites, and any changes would depend on other metabolic factors.
Choice D reason: Spironolactone can lead to decreased sodium levels due to its action as a diuretic that promotes sodium excretion while retaining potassium. This is particularly relevant in clients with liver failure and ascites, where fluid and electrolyte management is crucial.
Correct Answer is C
Explanation
Choice A reason: Having a glass of juice the morning of surgery may not be allowed, depending on the preoperative fasting guidelines. This statement could indicate a need for further clarification on preoperative instructions, but it is less critical than the misconception about eating solid food postoperatively.
Choice B reason: Taking time to relax if nervous the night before surgery is a healthy coping mechanism and does not indicate a lack of understanding about the surgery.
Choice C reason: The belief that the client will be able to eat solid food immediately after waking up from anesthesia is incorrect and indicates a need for further teaching. Postoperative dietary restrictions are typically in place, starting with clear liquids and gradually progressing to solid foods as tolerated.
Choice D reason: Understanding the risks associated with the surgery indicates that the client has received and comprehended the relevant information about the procedure.
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