A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Polyuria

Peripheral edema

Decreased respirations

Absent bowel sounds

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.

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Correct Answer is B

Explanation

Choice A Reason:

"I can take my partner outside of the room as long as they wear a mask."MRSA contact precautions typically involve limiting the spread of the bacteria. Taking the partner outside the room while wearing a mask might not be sufficient for infection control, as MRSA can spread through direct contact with surfaces. This statement might not indicate a full understanding of MRSA precautions.

Choice B Reason:

"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of infection control for MRSA. Washing hands with soap and water or using alcohol-based hand sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.

Choice C Reason:

"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that might involve contact with the patient's bodily fluids or surfaces that might be contaminated is recommended for MRSA precautions. This statement aligns with infection control practices.

Choice D Reason:

"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves should be disposed of after each use and hands washed thoroughly.

A. Positive Trousseau's sign B. Dizziness upon standing C. Tingling of the fingers D. Increased respiratory rate

Correct Answer is D

Explanation

Choice A Reason:

Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.

Choice B Reason:

Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.

Choice C Reason:

Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.

Choice D Reason:

Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.

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A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Nursing Test Bank

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Explanation

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