A nurse is assessing a client with suspected peritonitis. Which clinical finding is a hallmark sign of this condition?
Severe headache and neck stiffness
Rapid and shallow breathing
Abdominal rigidity and tenderness
Hyperactive bowel sounds
The Correct Answer is C
Choice A reason:
Severe headache and neck stiffness are signs of meningitis and are not directly related to peritonitis.
Choice B reason:
Rapid and shallow breathing may occur with other respiratory conditions but is not a hallmark sign of peritonitis.
Choice C reason:
Abdominal rigidity and tenderness are hallmark signs of peritonitis and are caused by the inflammation of the peritoneum.
Choice D reason:
Hyperactive bowel sounds may occur with gastrointestinal disorders but are not specific to peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Increased blood pressure is not characteristic of septic shock. Septic shock is associated with low blood pressure.
Choice B reason:
Bradycardia is not a typical sign of septic shock. Tachycardia is more common in septic shock.
Choice C reason:
Warm, flushed skin is not typical in septic shock. Septic shock is associated with cold, clammy skin.
Choice D reason:
Rapid, shallow breathing is a common early sign of septic shock and indicates the body's attempt to compensate for the decreased cardiac output.
Correct Answer is B
Explanation
Choice A reason:
Assessing for peripheral edema is important for clients with various conditions, but it is not directly related to the potential complications of peritonitis.
Choice B reason:
Monitoring blood glucose levels regularly is essential in clients with peritonitis, as hyperglycemia can be a complication of the inflammatory response and stress associated with the condition.
Choice C reason:
Encouraging fluid intake is essential 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:
Implementing fall precautions is important for clients at risk of falls, but it is not directly related to potential complications of peritonitis.
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