A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?
Generalized abdominal pain
Increased heart rate
Cloudy effluent
Fever
The Correct Answer is C
C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.
A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.
B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.
D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.
A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.
B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.
C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.
Correct Answer is B
Explanation
Correct choice:right infront of the ear
Rationale
Chvostek's sign is a clinical indicator of hypocalcemia (low calcium levels in the blood). It suggests increased neuromuscular irritability due to low calcium levels affecting nerve excitability.
To elicit Chvostek's sign, the examiner taps lightly over the facial nerve in front of the earlobe. A positive response is observed as twitching or spasm of the facial muscles, typically the lips, nose, and cheek on the same side.
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