A nurse is caring for a client with peritonitis and observes a rigid, board-like abdomen upon palpation. The nurse recognizes this finding as:
Rebound tenderness
Paralytic ileus
Abdominal compartment syndrome
Guarding
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Referred pain is pain that is felt in a different location from its source, and it is not directly associated with the sharp, sudden-onset pain described by the client.
Choice B reason:
Visceral pain arises from the internal organs and is often described as sharp and colicky. It worsens with movement and is a characteristic feature of peritonitis.
Choice C reason:
Neuropathic pain is caused by nerve damage and is not typically associated with peritonitis.
Choice D reason:
Radiating pain is pain that extends from its source to other areas, and it is not specifically described in the scenario.
Correct Answer is A
Explanation
Choice A reason:
Abdominal distension and decreased bowel sounds are classic signs of paralytic ileus, a common complication of peritonitis.
Choice B reason:
Gastroenteritis is inflammation of the gastrointestinal tract and may cause diarrhea and abdominal pain but is not related to the specific symptoms described.
Choice C reason:
Appendicitis is inflammation of the appendix and is not related to abdominal distension and decreased bowel sounds.
Choice D reason:
Constipation may cause abdominal distension, but decreased bowel sounds are not characteristic of constipation.
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