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 D
Explanation
Choice A reason:
Continuous gastric suction is not primarily intended to prevent aspiration pneumonia, although it may indirectly help reduce the risk of aspiration in some cases.
Choice B reason:
Reducing intra-abdominal pressure is not the primary purpose of continuous gastric suction, although it may have some effect on the overall abdominal pressure.
Choice C reason:
Continuous gastric suction is not primarily intended to manage pain and discomfort in the client with peritonitis, although it may help alleviate some symptoms.
Choice D reason:
Promoting bowel rest is the main purpose of continuous gastric suction in the management of peritonitis. By reducing the workload of the gastrointestinal tract, the inflamed peritoneum can heal and recover more effectively.
Correct Answer is B
Explanation
Choice A reason:
Referred pain is pain that is felt in a different location from its source, and it is not directly associated with the sharp, sudden-onset pain described by the client.
Choice B reason:
Visceral pain arises from the internal organs and is often described as sharp and colicky. It worsens with movement and is a characteristic feature of peritonitis.
Choice C reason:
Neuropathic pain is caused by nerve damage and is not typically associated with peritonitis.
Choice D reason:
Radiating pain is pain that extends from its source to other areas, and it is not specifically described in the scenario.
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