A client with peritonitis presents with an elevated temperature, rapid heart rate, and shallow breathing. The nurse recognizes these signs as indicative of:
Hypothermia
Hypertension
Hyperventilation
Systemic inflammatory response
The Correct Answer is D
Choice A reason:
Hypothermia refers to abnormally low body temperature and is not associated with the clinical presentation of peritonitis.
Choice B reason:
Hypertension refers to high blood pressure and is not directly associated with the signs of peritonitis.
Choice C reason:
Hyperventilation involves rapid breathing but may not always be present in peritonitis.
Choice D reason:
The client's elevated temperature, rapid heart rate, and shallow breathing are indicative of a systemic inflammatory response, which is a characteristic feature of peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Abdominal compartment syndrome may present with abdominal distension and firmness but is not directly associated with hypotension and tachycardia.
Choice B reason:
Respiratory distress syndrome may manifest with respiratory symptoms such as dyspnea and decreased oxygen saturation but is not directly associated with hypotension and tachycardia.
Choice C reason:
Sepsis is a systemic inflammatory response to infection and can cause hypotension and tachycardia as part of its clinical presentation.
Choice D reason:
Gastrointestinal bleeding may present with symptoms such as melena or hematemesis but is not directly associated with hypotension and tachycardia.
Correct Answer is C
Explanation
Choice A reason:
Anxiety may lead to restlessness, but the assumption of a fetal position suggests a pain response, which is a common finding in peritonitis.
Choice B reason:
Fatigue may lead to restlessness, but it does not explain the assumption of a fetal position, which is a pain-coping mechanism.
Choice C reason:
The client assuming a fetal position and exhibiting restlessness are indicative of pain, which is a common symptom in peritonitis.
Choice D reason:
Respiratory distress is not directly related to the findings described in the scenario.
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