The nurse assesses a client admitted four hours ago with a diagnosis of diverticulitis. Which clinical manifestation must be reported immediately to the physician?

Temperature-101.2

Bowel sounds change from normoactive to absent

Left lower quadrant discomfort

WBC count is slightly elevated

Answer and Explanation

The Correct Answer is B

B. Bowel sounds are typically present and indicate normal gastrointestinal motility. A change from normoactive (normal) to absent bowel sounds can indicate bowel obstruction, perforation, or peritonitis, which are serious complications of diverticulitis. This change warrants immediate reporting to the physician as it may indicate a worsening condition requiring urgent intervention.
A. A temperature of 101.2°F (38.4°C) is slightly elevated and may indicate the presence of infection, which is concerning in the context of diverticulitis. Fever is a common symptom of diverticulitis, but an elevated temperature may also suggest worsening infection or the development of complications such as abscess formation or perforation.
C. Left lower quadrant discomfort is a common symptom of diverticulitis due to inflammation in the sigmoid colon, where diverticula are most prevalent. While discomfort is expected in diverticulitis, the severity and persistence of pain should be assessed.
D. An elevated white blood cell (WBC) count is indicative of inflammation or infection and is commonly seen in diverticulitis. However, the significance of the elevation depends on the degree of increase and the presence of other clinical findings.

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Correct Answer is C

Explanation

C. Crohn's disease exacerbation often leads to malnutrition due to decreased oral intake, malabsorption, and increased nutrient losses through diarrhea. Addressing imbalanced nutrition is crucial to replenish depleted nutrient stores, support healing, and prevent further complications.
A. While fluid overload can be a concern in certain situations, such as when administering intravenous fluids or in clients with renal impairment, it is not typically a primary concern in clients hospitalized with Crohn's disease exacerbation. Crohn's disease is more commonly associated with dehydration due to diarrhea and malabsorption rather than fluid overload.
B. In the acute phase of Crohn's disease exacerbation, addressing immediate physiological needs and stabilizing the client's condition typically take precedence over psychosocial concerns.
D. Social isolation can be a concern for clients with chronic illnesses, including Crohn's disease, as it may impact their quality of life and emotional well-being. However, in the acute phase of exacerbation, addressing physiological needs and stabilizing the client's condition typically takes precedence over psychosocial concerns such as social isolation.

A. Administration of glucagon B. Large amounts of IV saline solution C. Long-acting IV insulin D. Oxygen by nasal cannula

Correct Answer is B

Explanation

B. Large amounts of IV saline solution: This is the correct initial therapy. HHNK is characterized by severe dehydration due to osmotic diuresis resulting from hyperglycemia. Therefore, the administration of large amounts of IV saline solution is essential to correct dehydration, restore intravascular volume, and improve tissue perfusion.
A. Glucagon is typically administered to treat severe hypoglycemia, not hyperglycemia.
C. Short-acting or regular insulin is administered initially to lower blood glucose levels rapidly. Long-acting insulin formulations may be used later to maintain glycemic control once the acute phase is managed.
D. Oxygen therapy may be indicated if the client is hypoxic, but it is not the initial therapy for HHNK. The priority in HHNK is to correct dehydration and hyperglycemia through fluid resuscitation and insulin therapy, respectively.

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The nurse assesses a client admitted four hours ago with a diagnosis of diverticulitis. Which clinical manifestation must be reported immediately to the physician?

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Naxlex Comprehensive Predictor Exams

The nurse is writing a care plan for a client who was diagnosed with Crohn's disease a year ago and is now hospitalized with a fourth acute exacerbation. Which client problem should receive the highest priority?

Correct Answer is C

Explanation

A client with Type 2 diabetes is brought into the emergency room in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNK) is made. The nurse prepares for the administration of which initial therapy?

Correct Answer is B

Explanation

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