LPN Nursing · Lower GI Disorders · Practice question
A nurse is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client has manifestations of ____ therefore, the priority finding for the nurse to report is____
History and Physical
Client admitted to the medical-surgical unit with severe, acute abdominal pain, abdominal distention, diarrhea, mucus and small amount of blood in the stool, and a 12% weight loss over the past 2 months.
Client's weight 2 months ago was 100.3 kg (221.1 lb). Client has a history of Crohn's disease and a seizure disorder that is managed with diet and medication.
Respirations are equal and unlabored. S1S2 heart tones auscultated. Abdominal assessment performed with muscle guarding and tenderness in the right lower quadrant noted on palpation. Abdomen is firm and rigid upon examination. Abdominal pain rated as an 8 on a scale of 0 to 10. Client states that pain is constant and localized in the lower right abdominal quadrant. Reports anorexia. Hypoactive bowel sounds noted upon auscultation.
Nurse's Note
0730:
Admission history and physical completed and documented. Provider notified of findings and will provide further prescriptions. Plan of care initiated.
Graphic Record
Day 1
1700:
Temperature 38.5°C (101.4°F)
Heart rate 102/min
Respiratory rate 18/min
Blood pressure 136/78 mm Hg
Oxygen saturation 97% on room air
1200:
Temperature 38.9°C (1 02°F)
Heart rate 112/min
Respiratory rate 22/min
Blood pressure 104/68 mm Hg
Oxygen saturation 96% on room air
Laboratory Results
Day 1:
Hgb 12 g/dL (12 to 168 g/dL female)
Hct (37% to 4752% female)
WBC count 19,000/mm3 (5,000 to 10,000/mm3)
Neutrophils (55% to 70%)
Erythrocyte sedimentation rate (ESR) 18 mm/hr (less than 15 mm/hr)
Medication Administration Record
Day 1:
Phenytoin 200 mg PO daily
Vital Signs
Day 1 0700:
Temperature 38.3° C (101° F)
Heart rate 102/min
Respiratory rate 18/min
Blood pressure 142/88 mm Hg
Oxygen saturation 97% on room air
Day 1 1300:
Temperature 38.9° C (102° F)
Heart rate 112/min
Respiratory rate 22/min
Blood pressure 104/68 mm Hg
Oxygen saturation 96% on room air
Diagnostic Results
Day 1 0700:
Hgb 12 g/dL (12 to 18 g/dL)
Hct 34% (37% to 52%)
Medication Administration Record
Day 1 0700:
Phenytoin 200 mg PO daily
Diagnostic Results
Day 1 0700:
Hgb 12 g/dL (12 to 18 g/dL)
Hct 34% (37% to 52%)
Day 1 0800:
WBC count 19,000/mm³ (5,000 to 10,000/mm³)
Neutrophil count 75% (55% to 70%)
RBC count 4 million/mm³ (4.2 million to 6.1 million/mm³)
Erythrocyte sedimentation rate (ESR) 18 mm/hr (less than or equal to 15 mm/hr)
Medication Administration Record
Day 1 0700:
Phenytoin 200 mg PO daily
Day 4
Hydrocodone/acetaminophen 10 mg/325 mg PO every 4 hr
PRN pain
Provider Prescriptions
Day 1 1300:
Prepare the client for an exploratory laparotomy.
Answer & explanation
Correct:
The clinical findings in this case strongly point to peritonitis rather than the other listed conditions. The client presents with a rigid, firm abdomen, muscle guarding, rebound tenderness in the right lower quadrant, elevated WBC of 19,000/mm³ with neutrophilia at 75%, fever of 38.9°C, tachycardia, a drop in blood pressure, and an elevated ESR. These are hallmark signs of peritoneal inflammation, consistent with a complication of the client's Crohn's disease such as perforation or abscess. The provider has already prescribed an exploratory laparotomy, which is the definitive surgical treatment for peritonitis, further confirming this diagnosis. Among the listed options, gastroenteritis, hepatitis, peptic ulcer disease, and pericarditis do not align with the combination of right lower quadrant rigidity, guarding, systemic inflammatory markers, and the need for emergent abdominal surgery. Once peritonitis is identified as the condition, the priority finding to report is the drop in blood pressure, which indicates hemodynamic compromise and potential septic shock — an immediately life-threatening consequence. The keyed answer identifies peritonitis correctly for the condition, but selects bowel sounds as the priority finding, which is incorrect. Hypotension is the most critical reportable finding; however, among the available options in blank 2, the laboratory values reflecting severe infection (elevated WBC, neutrophilia, elevated ESR) represent the most actionable objective data to report, making laboratory values the best match.
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