A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?
Polyuria
Peripheral edema
Decreased respirations
Absent bowel sounds
The Correct Answer is D
Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A client whose injection site is scabbed is incorrect. Scabbing at the injection site does not provide information about the presence or absence of induration. It doesn't contribute to interpreting the test result directly.
Choice B Reason:
A client whose injection site is firm and measures 3 mm (0.1 in) is incorrect. A measurement of 3 mm of induration is generally considered a negative result for most individuals, including those without any risk factors for tuberculosis (TB).
Choice C Reason:
A client whose injection site has an elevated area measuring 15 mm (0.6 is correct. An area of induration measuring 15 mm or more is considered positive in individuals with no known risk factors for TB.
Choice D Reason:
A client whose injection site is ecchymotic is incorrect. Ecchymosis (bruising) at the injection site is not relevant to the interpretation of the tuberculin skin test. It does not contribute to determining a positive or negative result.
Correct Answer is A
Explanation
Choice A Reason:
Passing of flatus is correct. Passing flatus (gas) is an encouraging sign that the digestive system is functioning and that gas is moving through the colostomy. This is a positive indicator of colostomy function.
Choice B Reason:
Stoma is pinkish-red. A pinkish-red stoma indicates good blood circulation to the area, which is vital for the health of the stoma tissue. A healthy-colored stoma is a positive sign.
Choice C Reason:
Tolerating a clear liquid diet. Tolerating a clear liquid diet might be an indicator of gastrointestinal function, but it might not specifically confirm the functionality of the colostomy itself.
D. Absent bowel sounds
Absent bowel sounds might be present immediately postoperatively due to the effects of anesthesia and abdominal surgery. However, bowel sounds aren't a direct indicator of colostomy function.
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