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A nurse assesses a client who is hospitalized for diverticulitis. The client's vital signs are temperature: 99.8°F (37.6°C), heart rate: 100 beats/min, respiratory rate: 18 breaths/min, and blood pressure: 100/62 mm Hg. Which action should the nurse take first?
- A. Decrease stimulation and allow the client to rest.
- B. Stay with the client while another nurse calls the provider.
- C. Increase the client's intravenous fluid replacement rate.
- D. Check the client's blood glucose and administer orange juice.
Correct Answer: B
Rationale: The client's vital signs suggest possible hypovolemia or early sepsis due to diverticulitis (elevated heart rate, low blood pressure, and mild fever). Staying with the client and having another nurse contact the provider ensures rapid assessment and intervention. Rest, fluid rate increase, or glucose checks are not the priority without further assessment.
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A nurse cares for a client who has food poisoning resulting from a Clostridium botulinum infection. Which assessment should the nurse complete first?
- A. Heart rate and rhythm
- B. Bowel sounds
- C. Urinary output
- D. Respiratory rate
Correct Answer: D
Rationale: Clostridium botulinum infection can cause respiratory failure due to neurotoxin effects. Assessing respiratory rate and oxygen saturation is the priority to detect early signs of respiratory compromise. Other assessments are important but secondary.
A nurse assesses a client with Crohn's disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Distended abdomen
- B. Temperature of 100.0°F (37.8°C)
- C. Loose and bloody stool
- D. Abdominal cramps
Correct Answer: A
Rationale: Colonic strictures predispose the client to intestinal obstruction. A distended abdomen may indicate an obstruction, requiring urgent notification of the provider. Low-grade fever, loose and bloody stools, and abdominal cramps are common symptoms of Crohn's disease and do not require immediate intervention.
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- A. Distended abdomen
- B. Diminished bowel sounds
- C. Bradycardia
- D. Hyperactive bowel sounds
- E. Inability to pass flatus or feces
- F. Tachycardia
Correct Answer: A,B,E,F,G
Rationale: Peritonitis presents with a distended abdomen, diminished bowel sounds, inability to pass flatus or feces, tachycardia, and decreased urine output due to inflammation and dehydration. Bradycardia and hyperactive bowel sounds are not associated with peritonitis.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.)
- A. Lower gastrointestinal bleeding - Erosion of the bowel wall
- B. Abscesses - Localized pockets of infection develop in the ulcerated bowel lining
- C. Toxic megacolon - Transmural inflammation resulting in pyuria and fecaluria
- D. Non-mechanical bowel obstruction - Paralysis of colon resulting from colorectal cancer
- E. Fistulas - Dilation and decreased motility caused by paralysis of the colon
Correct Answer: A,B,D
Rationale: Lower GI bleeding results from bowel wall erosion, abscesses form in ulcerated bowel lining, and non-mechanical bowel obstruction occurs due to colon paralysis from colorectal cancer. Toxic megacolon involves colon dilation, not pyuria/fecaluria, and fistulas result from transmural inflammation, not paralysis.
A nurse assesses a client who is hospitalized with an exacerbation of Crohn's disease. Which clinical manifestation should the nurse expect to find?
- A. Positive Murphy's sign with rebound tenderness to palpation
- B. Dull, hypoactive bowel sounds in the lower abdominal quadrant
- C. High-pitched, rushing bowel sounds in the right lower quadrant
- D. Reports of abdominal cramping that is worse at night
Correct Answer: C
Rationale: High-pitched, rushing bowel sounds are expected in Crohn's disease due to narrowing of the bowel lumen. Positive Murphy's sign indicates gallbladder disease, and rebound tenderness suggests peritonitis. Dull, hypoactive bowel sounds and nightly worsening of cramping are not typical of Crohn's disease.