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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Abdominal pain and cramping are common symptoms of diverticular disease, particularly diverticulosis and diverticulitis. The pain is often located in the lower left abdomen and can range from mild to severe. Cramping may occur due to inflammation or spasms in the affected colon segment.
A. Frequent urination is not a common symptom of diverticular disease. Diverticular disease typically involves symptoms related to the gastrointestinal tract, such as abdominal pain, changes in bowel habits, and rectal bleeding.
C. Symptoms related to the chest are more commonly associated with cardiovascular or respiratory conditions rather than gastrointestinal conditions like diverticular disease.
D. Joint stiffness is more commonly associated with musculoskeletal conditions such as arthritis or other inflammatory disorders.
Correct Answer is ["A","B","D","E"]
Explanation
A. Keeping the client NPO (nothing by mouth) helps to rest the gastrointestinal tract, reduces the risk of further obstruction, and prevents exacerbation of symptoms such as vomiting.
B. Measuring abdominal girth is an important nursing assessment for a client with a possible small bowel obstruction. An increase in abdominal girth can indicate abdominal distension, which is a common sign of bowel obstruction.
C. Severe abdominal pain is a common symptom of bowel obstruction, and opioids may be necessary to manage pain effectively. However, opioids should be used cautiously due to the risk of exacerbating bowel obstruction by reducing bowel motility.
D. Fluid replacement therapy is important for clients with small bowel obstruction, especially if they are vomiting or have fluid loss due to intestinal secretions. Intravenous fluids may be administered to maintain hydration, correct electrolyte imbalances, and prevent dehydration.
E. Radiologic studies, such as abdominal X-rays or computed tomography (CT) scans, are often used to confirm the diagnosis of small bowel obstruction and assess its severity.
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