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NurseDive Free Nursing Practice Question
A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
A. Rigid abdomen
A rigid abdomen might indicate more severe conditions such as peritonitis or a surgical emergency but isn't typically an expected finding in a client with diarrhea.
B. Hypothermia
Hypothermia is incorrect. While diarrhea can potentially lead to dehydration, which in turn might impact body temperature regulation, hypothermia itself is not a typical finding related to diarrhea.
C. Dehydration
Dehydration is correct. Diarrhea can lead to excessive fluid loss, resulting in dehydration. Symptoms might include increased thirst, dry mouth, decreased urine output, dry skin, fatigue, and dizziness. Dehydration is a common concern in individuals with prolonged diarrhea due to the loss of fluids and electrolytes.
D. Decreased bowel sounds
Decreased bowel sounds in cases of severe diarrhea or bowel obstruction, bowel sounds might be hyperactive or absent, but decreased bowel sounds might not necessarily be a consistent finding in all cases of diarrhea.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Fundamentals proctored exam 2. Take the full exam now
Similar Questions
A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed-suction drains in place. Which of the following interventions should the nurse include in the plan?
A. Irrigate the nasogastric tube with tap water.
Irrigate the nasogastric tube with tap water is incorrect. Irrigating the nasogastric tube with tap water isn't a standard nursing intervention and could risk altering electrolyte balance or causing other complications.
B. Mark abdominal girth once daily.
Mark abdominal girth once daily is correct. For a client who has undergone peritoneal lavage for peritonitis and has a nasogastric tube and closed-suction drains, marking the abdominal girth once daily is an essential intervention. Monitoring the abdominal girth helps assess for changes that might indicate the accumulation of fluid or distention, which could suggest complications like intra-abdominal bleeding or increased peritoneal fluid.
C. Place the client in a high Fowler's position.
Place the client in a high Fowler's position is incorrect. Positioning the client in high Fowler's position might provide comfort but isn't specifically related to the interventions required for a postoperative client following peritoneal lavage and drains placement.
D. Ambulate the client twice daily.
Ambulate the client twice daily is incorrect. Early ambulation is generally encouraged postoperatively for many clients, but in the immediate recovery phase following peritoneal lavage for peritonitis, it might not be the most immediate or specific priority.
A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching
A. Ground beef
Ground beef can be included in a soft diet as it can be cooked until it's tender and easily chewable.
B. Raw vegetables
Raw vegetables are generally excluded from a soft diet as they can be difficult to chew and digest. Steamed or cooked vegetables without skins or seeds are preferable.
C. Fruit with the skin
Fruits with tough skins or seeds should typically be avoided on a soft diet. Instead, fruits should be peeled and possibly cooked or canned.
D. High-fiber cereals
High-fiber cereals might not be suitable for a soft diet, as they often have a rough texture that can be difficult to chew and digest.
A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?
A. Dark-colored urine
Dark-colored urine is correct. This is a common sign of dehydration. When the body lacks adequate hydration, the urine becomes more concentrated, resulting in a darker color.
B. High blood pressure
High blood pressure is incorrect. Dehydration often leads to a decrease in blood volume, which can result in lower blood pressure rather than higher.
C. Distended neck veins
Distended neck veins is incorrect. Dehydration usually causes a decrease in fluid volume in the body, leading to a reduction in vein distension rather than an increase.
D. Moist skin
Moist skin is incorrect. Dehydration commonly causes dry skin due to reduced water content in the body, leading to a lack of moisture rather than increased skin moisture.