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 B
Explanation
Choice A reason:
Correcting electrolyte imbalances is important in fluid resuscitation, but the primary goal is to prevent circulatory collapse and restore hemodynamic stability.
Choice B reason:
The primary goal of fluid resuscitation in peritonitis is to prevent circulatory collapse and maintain adequate blood pressure and perfusion to vital organs.
Choice C reason:
Maintaining adequate urine output is one of the indicators of effective fluid resuscitation, but it is not the primary goal in this context.
Choice D reason:
Restoring fluid balance is a goal of fluid resuscitation, but the primary focus is on preventing circulatory collapse and ensuring adequate tissue perfusion.
Correct Answer is C
Explanation
Choice A reason:
Cholecystitis is inflammation of the gallbladder, which is not related to a ruptured appendix.
Choice B reason:
Gastritis is inflammation of the stomach lining, which may cause abdominal pain but is not related to a ruptured appendix.
Choice C reason:
Peritonitis is inflammation of the peritoneum, the membrane lining the abdominal cavity. It can occur as a complication of a ruptured appendix and presents with severe abdominal pain, tenderness, and fever.
Choice D reason:
Diverticulitis is inflammation of the diverticula (small pouches) in the colon and is not related to a ruptured appendix.
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