A nurse is collecting data from a client who has peritonitis.Which of the following findings should the nurse expect?
Decreased respirations.
Absent bowel sounds.
Peripheral edema.
Polyuria.
The Correct Answer is B
Choice A rationale
Peritonitis usually leads to increased respiratory rate rather than decreased respirations due to abdominal pain and possible sepsis. Rapid breathing is a common symptom as the body tries to compensate for the infection and discomfort.
Choice B rationale
Absent bowel sounds are a hallmark sign of peritonitis, indicating a lack of intestinal activity due to severe inflammation of the peritoneum. This condition can lead to ileus, where the intestines stop functioning properly.
Choice C rationale
Peripheral edema is not typically associated with peritonitis. Peritonitis primarily affects the abdomen and does not commonly cause fluid accumulation in the extremities. Edema is more related to conditions affecting the heart, liver, or kidneys.
Choice D rationale
Polyuria, or excessive urination, is not a symptom of peritonitis. Peritonitis primarily affects the abdominal cavity and symptoms include severe abdominal pain, fever, and a rigid abdomen. Polyuria is often associated with conditions like diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Dimming the lighting in the client's room helps reduce photophobia and headaches, which are common symptoms in viral meningitis.
Choice A rationale
Monitoring temperature every 6 hours is not as frequent as needed. Frequent monitoring is crucial due to the risk of rapid changes in condition.
Choice C rationale
Contact precautions are not necessary for viral meningitis, as it is not as contagious as bacterial meningitis. Standard precautions are generally sufficient.
Choice D rationale
Measuring intake and output every 8 hours is standard, but it is not specific to the needs of a viral meningitis patient like controlling environmental stimuli.
Correct Answer is A
Explanation
Choice A rationale
An inability to remain fully awake while answering questions indicates a potential decline in neurological function, possibly due to a serious head injury such as a concussion or intracranial hemorrhage. Prompt medical attention is necessary to prevent further complications.
Choice B rationale
While inability to answer a judgment question correctly may indicate cognitive impairment, it is not as urgent as a diminished level of consciousness, which can signal a severe injury.
Choice C rationale
Inability to remember their adult children's names could be a sign of cognitive decline, but it is not immediately life-threatening. Priority should be given to assessing the client's level of consciousness.
Choice D rationale
Difficulty repeating the names of three common objects can indicate short-term memory impairment, but it is not as critical as an altered level of consciousness, which requires immediate intervention.
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