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

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Thirst, polyuria, and abdominal pain are symptoms commonly associated with hyperglycemia. High blood glucose levels can lead to osmotic diuresis, causing increased urination and thirst. Abdominal pain may occur due to gastrointestinal symptoms related to hyperglycemia, such as bloating or discomfort.
A. Blurred vision, weakness, tingling of extremities are more indicative of hypoglycemia rather than hyperglycemia.
B. Hunger, shakiness, confusion are symptoms of hypoglycemia rather than hyperglycemia.
D. While tachycardia and anxiety can occur with various medical conditions, oliguria is not typically associated with hyperglycemia.

A. Loops of large bowel become visibly outlined through the abdominal wall B. Intense thirst, parched tongue and dry mucous membranes C. Vomiting of bile-stained gastric contents D. High-pitched, frequent bowel sounds

Correct Answer is A

Explanation

A. Loops of large bowel become visibly outlined through the abdominal wall is a typical late clinical finding of a large bowel obstruction. In fact, visible loops of bowel through the abdominal wall may be observed in cases of a severe bowel obstruction, but it is not typically considered a late finding.

B. Intense thirst, parched tongue, and dry mucous membranes suggest dehydration, which can occur as a result of vomiting, decreased fluid intake, or fluid loss due to the obstruction. However, dehydration may occur earlier in the course of a bowel obstruction and may not be considered a late finding.
C. Vomiting in large bowel obstruction is commonly of fecal contents.
D. High-pitched, frequent bowel sounds is not a typical late clinical finding of a large bowel obstruction. Instead, bowel sounds are usually diminished or absent in cases of bowel obstruction due to decreased peristalsis beyond the site of obstruction.

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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?

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Naxlex Comprehensive Predictor Exams

What symptoms would indicate to the nurse that the client receiving TPN is experiencing hyperglycemia?

Correct Answer is C

Explanation

The nurse is assessing a client who has a large bowel obstruction. Which late clinical finding would the nurse expect?

Correct Answer is A

Explanation

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