A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Choice A Reason:
Peripheral edema is typically associated with conditions that cause fluid retention or circulatory issues, such as heart failure, kidney disease, or chronic venous insufficiency. While it can occur in a variety of systemic conditions, it is not a hallmark finding specifically associated with peritonitis.

Choice B Reason:
Polyuria, which is an increase in urine volume, is more commonly associated with conditions affecting the kidneys, such as diabetes or diuretic use. It is not a characteristic finding in peritonitis, which primarily affects the abdominal cavity.

Choice C Reason:
Absent bowel sounds are a significant finding in peritonitis. The inflammation of the peritoneum often leads to a paralytic ileus, where the bowel stops functioning properly. This can result in an absence of the normal gurgling sounds made by the intestines, which is a critical sign that healthcare providers look for when assessing for peritonitis.

Choice D Reason:
Decreased respirations may occur in peritonitis due to the pain and discomfort associated with the inflammation of the abdominal cavity, which can inhibit deep breathing. However, this is not as specific or diagnostic as absent bowel sounds. Respiratory rate changes can be influenced by a variety of factors, including pain, medications, and systemic infections.

Choice A Reason:
Ecchymosis at the injection site does not indicate a positive tuberculin skin test. Ecchymosis is a sign of bleeding under the skin, which may be due to the needle insertion but is not related to the immune response measured by the test.

Choice B Reason:
Scabbing at the injection site is also not indicative of a positive tuberculin skin test. Scabbing can occur as a natural part of the healing process after the skin has been punctured and does not reflect the immune system's reaction to the tuberculin antigen.

Choice C Reason:
An elevated area measuring 15 mm (0.6 in) at the injection site is considered a positive result for a tuberculin skin test¹²³. This indicates that the person's immune system has reacted to the tuberculin antigen, suggesting a previous or current infection with tuberculosis bacteria.

Choice D Reason:
A firm area measuring 3 mm (0.1 in) at the injection site is not considered a positive result for a tuberculin skin test. The size of the induration (raised area) is what determines a positive result, and in most cases, an induration of 15 mm or more is required for a positive diagnosis.