A client with peritonitis is at risk of developing septic shock. Which clinical manifestation should the nurse closely monitor to detect early signs of septic shock?
Increased blood pressure
Bradycardia
Warm, flushed skin
Rapid, shallow breathing
The Correct Answer is D
Choice A reason:
Increased blood pressure is not characteristic of septic shock. Septic shock is associated with low blood pressure.
Choice B reason:
Bradycardia is not a typical sign of septic shock. Tachycardia is more common in septic shock.
Choice C reason:
Warm, flushed skin is not typical in septic shock. Septic shock is associated with cold, clammy skin.
Choice D reason:
Rapid, shallow breathing is a common early sign of septic shock and indicates the body's attempt to compensate for the decreased cardiac output.
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Related Questions
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 managing sepsis, a life-threatening complication 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 broad-spectrum antibiotic therapy is more critical in managing sepsis.
Choice C reason:
Initiating broad-spectrum antibiotic therapy is the highest priority in managing sepsis. Prompt administration of antibiotics is crucial to treat the bacterial infection and prevent its spread.
Choice D reason:
Providing deep breathing exercises is important for preventing respiratory complications, but it is not the highest priority compared to addressing sepsis with antibiotics.
Correct Answer is D
Explanation
Choice A reason:
Rebound tenderness refers to increased pain upon release of pressure during palpation and is not related to the finding of a rigid, board-like abdomen.
Choice B reason:
Paralytic ileus refers to a condition in which the intestines stop functioning, causing a lack of bowel sounds and distension, but it is not directly related to the rigid abdomen finding.
Choice C reason:
Abdominal compartment syndrome may cause abdominal distension and increased intra-abdominal pressure, but it does not necessarily result in a rigid, board-like abdomen.
Choice D reason:
The finding of a rigid, board-like abdomen upon palpation is known as guarding, which is a protective response of the abdominal muscles in peritonitis to minimize movement and protect the inflamed peritoneum.
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