The nurse is caring for an adolescent with a ruptured appendix. What assessment findings would support the diagnosis of peritonitis?

Hyperactive bowel sounds

Profuse diarrhea

A hard, rigid abdomen

Abdominal cramping

Answer and Explanation

The Correct Answer is C

A.   This finding is generally not associated with peritonitis. Instead, hyperactive bowel sounds may indicate early gastrointestinal irritation or obstruction. In the case of peritonitis, bowel sounds are often diminished or absent due to the inflammation and irritation of the peritoneum.
B.   Profuse diarrhea is not a typical sign of peritonitis. While gastrointestinal disturbances can occur, diarrhea is more commonly associated with infections or irritations of the intestines rather than with peritonitis itself. Peritonitis typically presents with symptoms related to abdominal rigidity and pain.
C.   A hard, rigid abdomen is a classic sign of peritonitis. It indicates involuntary guarding, which occurs as a response to inflammation and irritation of the peritoneum. The rigidity reflects the body's protective mechanism against pain and is a significant assessment finding.

D.   While abdominal cramping can occur in various gastrointestinal conditions, it is not a specific indicator of peritonitis. In cases of peritonitis, the pain is often more severe and localized rather than cramping. The patient may experience sharp, steady pain that worsens with movement.

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Correct Answer is ["A","B","E"]

Explanation

A. Trauma to the eye can lead to retinal detachment. Understanding any history of eye injuries is crucial for assessing the likelihood of detachment.
B. Lifting heavy objects can increase intraocular pressure, which may contribute to retinal detachment, particularly in individuals with existing vulnerabilities. This question is relevant for assessing risk factors.
C. While sodium intake is important for general health, it is not directly related to the risk of retinal detachment. This question is not relevant in this context.
D. This statement is somewhat correct but less directly relevant. While protecting the eyes from UV light is important for overall eye health and can help prevent conditions that might lead to retinal issues, it is not a primary factor associated with retinal detachment.
E. Long-term use of steroids can increase the risk of retinal detachment, particularly in patients with certain conditions (like high myopia). This question is important for identifying potential risk factors.

A. A 33-year-old daycare worker at a high-risk center. B. A 54-year-old nurse working in a nursing home. C. A 16-year-old female high school student. D. A 43-year-old homeless man with a history of alcoholism.

Correct Answer is D

Explanation

A. While daycare workers can be at risk for various infections, they are not typically considered at high risk for TB unless they are in close contact with TB-positive individuals. Therefore, this option does not present the highest likelihood of TB.
B. This individual is at a moderate risk for TB, especially if they are caring for patients with known TB or are in an environment where TB may be more prevalent. However, nursing homes are more often associated with other infections rather than being primary sources for TB outbreaks.
C. High school students are generally not at high risk for TB unless they have specific exposure or travel history. Without additional risk factors, this group does not exhibit a high likelihood of TB.
D. This option represents the highest likelihood of TB. Homeless individuals are at increased risk for TB due to factors such as crowded living conditions, poor nutrition, and lack of access to healthcare.

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The nurse is caring for an adolescent with a ruptured appendix. What assessment findings would support the diagnosis of peritonitis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has suspected retinal detachment. Which of the following questions should the nurse include when gathering a client history? (Select All that Apply.)

Correct Answer is ["A","B","E"]

Explanation

The nurse is working in an outpatient clinic. The clinic has been alerted that there is an outbreak of tuberculosis (TB). Which of the following clients entering the clinic today are most likely to have TB?

Correct Answer is D

Explanation

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