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

Answer and Explanation

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

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Correct Answer is C

Explanation

C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.

A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.

B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.

D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP

A. The client advances the weaker leg forward to the cane. B. The client holds the cane with their left hand. C. The client takes a step with their right foot first. D. The client moves the cane 2 feet ahead.

Correct Answer is A

Explanation

A Advancing the weaker leg forward to the quad cane first indicates that the client understands the proper sequence of using the cane to support their weaker side. This action provides stability and reduces the risk of falls or imbalance.

B. Holding the cane with the opposite hand of the weaker side (right hand, in this case) is crucial to provide proper support and balance while walking. This distributes weight evenly and enhances stability.

C. Taking a step with the stronger foot first does not effectively support the weaker side and can lead to imbalance or falls, especially for a client with left-sided weakness.

D. While moving the cane ahead with each step is necessary, the distance of two feet is not specified in proper cane use. The cane should move forward incrementally with each step to maintain stability and support.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Correct Answer is C

Explanation

A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?

Correct Answer is A

Explanation

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