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    Adult Health med surg proctored exam (Viterbo university)

    The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?

    Explanation & Rationale

    Choice A reason: While performing a daily full head-to-toe assessment is important in comprehensive patient care, this answer does not specifically address why the nurse would be particularly concerned with assessing the abdomen in a burn patient.Choice B reason: Assessing for a paralytic ileus secondary to reduced blood flow is crucial in patients with serious burns. Burns can lead to significant physiological stress, which can decrease blood flow to the gastrointestinal tract. This reduction in blood flow can cause a paralytic ileus, a condition where the intestines do not move properly, leading to abdominal distention, pain, and decreased bowel sounds. Early detection is vital to prevent complications.Choice C reason: While nausea and vomiting related to pain medication are possible in burn patients, the primary concern in assessing the abdomen would be to identify more serious conditions such as a paralytic ileus. This answer does not capture the immediate criticality compared to assessing for paralytic ileus.Choice D reason: Monitoring for increased motility that may result in cramps and diarrhea is not the primary concern in burn patients. In fact, burn patients are more likely to experience decreased gastrointestinal motility due to the stress response and reduced blood flow rather than increased motility.

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