A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for
the nurse to monitor?
Heart atack
Diabetes
Respiratory failure
Sepsis
The Correct Answer is D
Choice A reason: While a heart atack is a serious condition, it is not directly related to peritonitis. Peritonitis can lead to systemic infection, which may indirectly affect the heart, but it is not the primary concern in the immediate care of peritonitis.
Choice B reason: Diabetes is a chronic condition that requires ongoing management. However, it is not the most immediate threat when a client is diagnosed with peritonitis. The nurse should continue to monitor blood glucose levels as part of routine care.
Choice C reason: Respiratory failure can be a complication of peritonitis if the infection spreads and affects other systems. However, the primary concern with peritonitis is the potential for the infection to lead to sepsis.
Choice D reason: Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body's response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Instructing the client to drink 1 liter of fluid each day may not be sufficient for someone with cystitis. Increasing fluid intake helps ?ush out bacteria from the urinary tract, and the general recommendation is to drink about 2 liters of water per day.
Choice B reason: While taking antibiotics is a crucial part of treating bacterial cystitis, the client should complete the full course of antibiotics prescribed, not just until symptoms such as dysuria disappear. This ensures the infection is fully treated and reduces the risk of resistance.
Choice C reason: Advising the client to avoid carbonated beverages is appropriate because such drinks can irritate the bladder and exacerbate symptoms of cystitis. It is also recommended to avoid ca?eine, alcohol, and spicy foods until the infection clears.
Choice D reason: There is no specific recommendation for clients with cystitis to drink tomato juice each day. In fact, tomato juice is acidic and may irritate the bladder, similar to carbonated beverages.
Correct Answer is B
Explanation
Choice A reason: While kidney infections can cause swelling, they typically do not lead to a significant increase in abdominal girth unless associated with severe obstruction or advanced kidney disease.
Choice B reason: In PKD, the kidneys can become significantly enlarged due to the growth of numerous cysts, which
can indeed lead to an increase in abdominal girth.
Choice C reason: While stones can cause blockage and swelling, they would not typically result in a generalized increase in abdominal girth unless there is an associated infection or severe obstruction.
Choice D reason: Inflammation can lead to fluid retention, but in the context of PKD, it is the cysts' growth that primarily contributes to increased kidney size and abdominal girth.
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