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A nurse is assessing a client with suspected peritonitis. Which clinical finding is a hallmark sign of this condition?

Severe headache and neck stiffness

Rapid and shallow breathing

Abdominal rigidity and tenderness

Hyperactive bowel sounds

Answer and Explanation

The Correct Answer is C

Choice A reason:

Severe headache and neck stiffness are signs of meningitis and are not directly related to peritonitis.

Choice B reason:

Rapid and shallow breathing may occur with other respiratory conditions but is not a hallmark sign of peritonitis.

Choice C reason:

Abdominal rigidity and tenderness are hallmark signs of peritonitis and are caused by the inflammation of the peritoneum.

Choice D reason:

Hyperactive bowel sounds may occur with gastrointestinal disorders but are not specific to peritonitis.

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Correct Answer is C

Explanation

Choice A reason:

Administering pain medication is important for the client's comfort, but it is not the highest priority in the management of peritonitis. Addressing the underlying infection with antibiotics takes precedence.

Choice B reason:

Monitoring vital signs is essential for assessing the client's condition, but initiating antibiotic therapy is more critical to address the underlying infection.

Choice C reason:

Initiating intravenous (IV) antibiotic therapy is the highest priority in the management of peritonitis. Prompt administration of antibiotics is essential to treat the bacterial infection and prevent its spread.

Choice D reason:

Encouraging deep breathing and coughing exercises is beneficial for preventing respiratory complications, but it is not the highest priority compared to addressing the infection with antibiotics.

A. Prevent aspiration pneumonia B. Relieve abdominal distension C. Monitor gastric pH levels D. Administer enteral nutrition

Correct Answer is B

Explanation

Choice A reason:

Preventing aspiration pneumonia is one of the benefits of an NG tube, but the primary purpose in peritonitis is to relieve abdominal distension caused by fluid and gas accumulation.

Choice B reason:

Relieving abdominal distension is the primary purpose of an NG tube in clients with peritonitis, as it helps remove fluid and gas from the stomach and intestines, reducing pressure on the peritoneum.

Choice C reason:

Monitoring gastric pH levels may be done with an NG tube in certain situations, but it is not the primary purpose in the context of peritonitis.

Choice D reason:

Administering enteral nutrition may be a secondary purpose of an NG tube in some cases, but it is not the primary goal in clients with peritonitis.

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A nurse is assessing a client with suspected peritonitis. Which clinical finding is a hallmark sign of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with peritonitis. Which intervention is the highest priority in the management of this condition?

Correct Answer is C

Explanation

A client with peritonitis is prescribed a nasogastric (NG) tube for decompression. The nurse understands that the primary purpose of the NG tube is to:

Correct Answer is B

Explanation

A client is diagnosed with spontaneous bacterial peritonitis (SBP). The nurse anticipates the need for which medical intervention?

A nurse is preparing a care plan for a client with peritonitis. Which nursing intervention is essential to include in the plan to address potential complications of this condition?

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A client with peritonitis is prescribed intravenous (IV) opioids for pain management. The nurse closely monitors the client for which potential side effect?

A client with peritonitis is experiencing abdominal distension and decreased bowel sounds. The nurse suspects the presence of:

A client with cirrhosis is admitted to the hospital with suspected peritonitis. The nurse understands that cirrhosis is a significant risk factor for peritonitis due to: