A nurse caring for a client with peritonitis observes the client assuming a fetal position and exhibiting restlessness. The nurse interprets these behaviors as indicative of:
Anxiety
Fatigue
Pain
Respiratory distress
The Correct Answer is C
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
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.
Correct Answer is D
Explanation
Choice A reason:
Monitoring blood glucose levels is important for clients with various conditions, but it is not directly related to the management of acute kidney injury (AKI) in peritonitis.
Choice B reason:
Administering pain medication is essential for managing the client's pain and providing comfort during treatment, but it is not directly related to the management of acute kidney injury.
Choice C reason:
Encouraging fluid intake is important for clients with peritonitis, but the specific recommendation of 3 liters per day is not universally applicable and may vary based on individual client needs and medical status.
Choice D reason:
Maintaining fluid and electrolyte balance is crucial in managing acute kidney injury in peritonitis. The nurse should closely monitor the client's fluid intake, output, and electrolyte levels and collaborate with the healthcare team to adjust the fluid therapy as needed.
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