The nurse suspects that the client, hospitalized with severe ulcerative colitis, is experiencing the complication of toxic megacolon. Which assessment finding would support this suspicion?
Increased passage of gas and stool
Enlarging abdominal girth
Hyperactive bowel sounds
Afebrile
The Correct Answer is B
B. Toxic megacolon is characterized by severe colonic dilation, leading to a significant increase in abdominal girth. As the colon becomes distended, it can cause visible abdominal swelling and bloating, which may be accompanied by tenderness upon palpation.
A. In the context of toxic megacolon, there may be a reduction or cessation of bowel movements due to colonic dilation and paralysis.
C. In toxic megacolon, bowel sounds may initially be hyperactive due to increased peristalsis as the colon attempts to overcome the obstruction. However, as the condition progresses, bowel sounds may diminish or become absent due to colonic dilation and paralysis.
D. While fever can be present in toxic megacolon due to the underlying inflammatory process, it is not universally seen in all cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Increase fiber in the diet: This is the correct option. Increasing dietary fiber intake is one of the most important interventions to prevent diverticular disease and reduce the risk of diverticulitis. Adequate fiber intake promotes regular bowel movements and prevents constipation, which can help reduce pressure in the colon and minimize the formation of diverticula.
A. Nuts and seeds are excellent sources of dietary fiber, which may actually help prevent diverticular disease. Therefore, while avoiding nuts and seeds may be advised during an acute diverticulitis flare-up to reduce irritation to the colon, it is not the most important long-term preventive intervention.
C. While stress management techniques may contribute to overall health and well-being, they are not the most important intervention specifically for preventing diverticular disease.
D. While physical activity and exercise are important for overall health and may help improve bowel function, there is limited evidence to suggest that strengthening abdominal muscles alone can prevent diverticular disease.
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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