A 45-year-old female patient is admitted to the emergency department with severe abdominal pain, fever, and nausea. She reports that the pain started suddenly and has progressively worsened. The healthcare provider suspects peritonitis and orders immediate interventions.
Physical examination
On examination, the patient has a distended abdomen, guarding, and rebound tenderness.
Her vital signs are as follows:
Temperature 102.4°F (39.1°C), Heart rate 120 bpm, Blood pressure 90/60 mmHg, and Respiratory rate 24 breaths per minute.
Which of the following complications is the nurse's highest priority to monitor for in this patient?
Intestinal obstruction
Hypovolemic shock
Electrolyte imbalance
Sepsis
The Correct Answer is B
A. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.
B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.
C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.
D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Eating contaminated food or water from an infected source can cause you to become infected with hepatitis C." This applies to hepatitis A, not hepatitis C. Hepatitis A is transmitted through the fecal-oral route, whereas hepatitis C is bloodborne.
B. "Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C." Hepatitis C is primarily spread through blood-to-blood contact, most commonly through sharing needles, blood transfusions before widespread blood screening, or needle-stick injuries.
C. "Coming into contact with an infected person's bodily fluids, such as saliva, can cause you to become infected with hepatitis C." Hepatitis C is not commonly spread through casual contact or saliva. The risk of transmission through bodily fluids other than blood is extremely low.
D. "Consuming a large amount of alcohol at one time can cause you to become infected with hepatitis C." Alcohol does not cause hepatitis C, though it can worsen liver damage in individuals already infected with the virus.
Correct Answer is A
Explanation
A. Instruct the patient to change positions slowly to prevent dizziness and falls. Ascites can cause a shift in fluid balance, leading to orthostatic hypotension. Changing positions slowly reduces the risk of dizziness and falls, which are common in patients with fluid shifts.
B. Advise the patient to avoid all physical activity to prevent exacerbation of symptoms: Complete avoidance of physical activity is not recommended. Mild activity may help with overall health and mobility unless contraindicated. Bedrest is typically only recommended for acute or severe cases.
C. Encourage the patient to drink plenty of fluids to prevent dehydration: Patients with ascites are often on fluid restrictions to manage excess fluid accumulation. Encouraging excess fluid intake can worsen the condition.
D. Recommend wearing tight clothing to support the abdominal area: Tight clothing could cause discomfort and increase abdominal pressure, which could exacerbate symptoms or complications related to ascites.
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