Nokea
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.
You may also like to solve these questions
A nurse cares for a client with a new ileostomy. The client states, 'I don't think my friends will accept me with this ostomy.' How should the nurse respond?
- A. Your friends will be happy you are alive.
- B. Tell me more about your concerns.
- C. A therapist can help you resolve your concerns.
- D. With time you will accept your new body.
Correct Answer: B
Rationale: Encouraging the client to express concerns addresses social anxiety and apprehension common with a new ostomy. Minimizing concerns, suggesting a therapist without discussion, or assuming acceptance over time are not therapeutic responses.
A nurse teaches a client how to avoid becoming ill with Salmonella infection again. Which statements should the nurse include in this client's teaching? (Select all that apply.)
- A. Wash your hands with hot water before eating.
- B. Cook foods thoroughly, especially poultry and eggs.
- C. Wash your hands before and after using the bathroom.
- D. Avoid eating raw or undercooked eggs and meats.
- E. Refrigerate leftovers promptly to prevent bacterial growth.
Correct Answer: B,C,D,E
Rationale: To prevent Salmonella infection, clients should cook foods thoroughly, wash hands before and after bathroom use, avoid raw or undercooked eggs and meats, and refrigerate leftovers promptly to inhibit bacterial growth. Hot water is not specifically required; soap and water are sufficient.
A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation should alert the nurse to urgently contact the health care provider?
- A. Pale and bluish stoma
- B. Liquid stool
- C. Ostomy pouch intact
- D. Blood-smeared output
Correct Answer: A
Rationale: A pale or bluish stoma indicates potential ischemia or poor perfusion, requiring urgent provider notification. Liquid stool and blood-smeared output are expected after ileostomy placement, and an intact pouch is normal.
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 cares for an older adult client who has Salmonella food poisoning. The clients vital signs are heart rate: 102 beats/min, blood pressure: 98/56 mm Hg. Which statement by the client indicates a need for additional teaching?
- A. I should not prepare food for others while I am sick.
- B. I will take the ciprofloxacin until the diarrhea has resolved.
- C. I should wash my hands with antibacterial soap before each meal.
- D. I must place my dishes into the dishwasher after each meal.
Correct Answer: B
Rationale: Ciprofloxacin should be taken for 10 to 14 days to treat Salmonella infection and should not be stopped once diarrhea resolves. Clients must complete the full course of antibiotics to prevent recurrence and resistance. Not preparing food for others, washing hands with antibacterial soap, and cleaning dishes thoroughly are correct practices to prevent the spread of infection.