36. A nurse is observing a client for possible complications of postoperative peritonitis. Which manifestations are most indicative of peritonitis? Select all that apply.
36. A nurse is observing a client for possible complications of postoperative peritonitis. Which manifestations are most indicative of peritonitis? Select all that apply.
. Hyperactive bowel sounds.
. Localized or diffuse pain.
. Abdominal rigidity.
. Shallow respirations.
. Temperature over 102°F.
Test-Taking Tip
Think about how inflammation affects the body system as each option is considered. Think "pain," as in Answers 2, 3, and 4.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because peristalsis is diminished and paralytic ileus may develop. Answer 2 is correct because the pain is often diffuse initially and then localized. Answer 3 is correct because the abdominal muscles are rigid and the abdomen is tender and distended. Answer 4 is correct because, with the abdominal tenderness and distention, the client will not breathe as deeply. Answer 5 is incorrect because the temperature is usually 100° to 101°F.