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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A reason:
Administering pain medication is important for the client's comfort, but it is not the highest priority in managing sepsis, a life-threatening complication of peritonitis. Addressing the underlying infection with antibiotics takes precedence.
Choice B reason:
Monitoring vital signs is essential for assessing the client's condition, but initiating broad-spectrum antibiotic therapy is more critical in managing sepsis.
Choice C reason:
Initiating broad-spectrum antibiotic therapy is the highest priority in managing sepsis. Prompt administration of antibiotics is crucial to treat the bacterial infection and prevent its spread.
Choice D reason:
Providing deep breathing exercises is important for preventing respiratory complications, but it is not the highest priority compared to addressing sepsis with antibiotics.
Correct Answer is C
Explanation
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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