Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

Correct Answer: A

Rationale: In the context of a client with peritonitis, the priority focus of nursing management is maintaining fluid and electrolyte balance (Option A). Peritonitis is a serious condition characterized by inflammation of the peritoneum, which can lead to fluid shifts, dehydration, and electrolyte imbalances. Addressing fluid and electrolyte balance is crucial in stabilizing the client's condition and preventing complications such as hypovolemic shock. Gastric irrigation (Option B) is not a priority in the management of peritonitis as it may exacerbate the inflammatory process and lead to further complications. Pain management (Option C) is important in providing comfort to the client but is secondary to addressing the physiological imbalances caused by peritonitis. Psychosocial issues (Option D) should also be addressed but are not the immediate priority in the acute phase of peritonitis. In an educational context, understanding the prioritization of nursing interventions based on the client's condition is essential for providing safe and effective care. By focusing on the underlying pathophysiology and immediate needs of the client, nurses can optimize outcomes and promote recovery in clients with complex medical conditions like peritonitis.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Metabolic alkalosis with hypokalemia. When a client vomits frequently, they lose hydrochloric acid from the stomach, leading to metabolic alkalosis. The loss of gastric contents also results in the loss of potassium, causing hypokalemia. Option A) Metabolic acidosis with hyperkalemia is incorrect because vomiting leads to the loss of acid, not an excess, and potassium is lost, not retained. Option B) Metabolic acidosis with hypokalemia is incorrect because vomiting causes metabolic alkalosis due to acid loss, not acidosis. Option C) Metabolic alkalosis with hyperkalemia is incorrect because vomiting results in hypokalemia due to potassium loss, not hyperkalemia. Educationally, understanding the electrolyte imbalances and acid-base disturbances that can result from vomiting is crucial in the care of patients with gastrointestinal issues. Recognizing these imbalances helps nurses provide appropriate interventions and prevent further complications. It also highlights the importance of monitoring electrolyte levels in patients with vomiting to prevent adverse outcomes.

Correct Answer: C

Rationale: The priority nursing diagnosis in this scenario is "Deficient fluid volume" (Option C). This is because a small-bowel obstruction can lead to significant fluid loss and dehydration due to the inability of fluid and contents to pass through the intestines. The insertion of a Miller-Abbott tube is aimed at decompressing the bowel and relieving the obstruction, which can result in further fluid loss. Therefore, addressing the deficient fluid volume is crucial to prevent complications such as hypovolemic shock and electrolyte imbalances. Option A, "Imbalanced nutrition: Less than body requirements," is not the priority in this situation as fluid volume deficit poses a more immediate threat to the client's physiological stability. While nutrition is important for recovery, addressing fluid volume deficit takes precedence. Option B, "Acute pain," is also important to address, but in the context of a small-bowel obstruction and the need for bowel decompression, fluid volume deficit poses a greater risk to the client's immediate well-being. Option D, "Excess fluid volume," is incorrect as there is no indication of fluid overload in this scenario. In fact, the client is more likely experiencing fluid volume deficit due to the obstruction. Educationally, understanding the priority nursing diagnosis in a specific clinical situation is crucial for providing safe and effective care to patients. This rationale highlights the importance of prioritizing interventions based on the client's immediate needs and the potential risks associated with the condition.

Correct Answer: D

Rationale: In teaching an elderly client how to prevent constipation, including regular exercise (option D) is crucial for several reasons. Exercise helps stimulate intestinal motility, promoting more regular bowel movements. It also enhances overall health and well-being in older adults by improving circulation, muscle tone, and metabolism. Additionally, physical activity can help alleviate stress, which may contribute to constipation. Option A, drinking 6 glasses of fluid daily, is important for overall hydration but alone may not be sufficient to prevent constipation. Adequate fluid intake should be encouraged, but exercise plays a more direct role in preventing constipation in this scenario. Avoiding grain products and nuts (option B) is not necessary for preventing constipation unless the individual has specific dietary sensitivities or intolerances to these foods. In fact, whole grains and nuts can provide essential dietary fiber, which is beneficial for bowel regularity. Adding 4 grams of bran to cereal (option C) may seem like a good way to increase fiber intake, but it is not as effective or sustainable as incorporating a variety of fiber-rich foods into the diet. Furthermore, some individuals may find bran difficult to digest, leading to potential gastrointestinal discomfort. In an educational context, it is important to emphasize a holistic approach to preventing constipation in the elderly, which includes a balanced diet rich in fiber, adequate hydration, regular physical activity, and addressing any underlying health conditions or medications that may contribute to constipation. Encouraging lifestyle modifications like exercise can empower older adults to take an active role in their digestive health and overall well-being.

Correct Answer: C

Rationale: In a client with diarrhea, the outcome that indicates fluid resuscitation is successful is when the client exhibits firm skin turgor. Firm skin turgor is a reliable indicator of adequate hydration status. When a person is dehydrated, their skin loses elasticity and becomes less turgid, whereas improved skin turgor suggests proper fluid balance has been restored. Option A, the client passing formed stools at regular intervals, is incorrect as it primarily reflects bowel motility and consistency, not necessarily hydration status. Option B, the client reporting a decrease in stool frequency and liquidity, is also incorrect as it may indicate symptom improvement but does not directly reflect hydration status. Option D, the client no longer experiencing perianal burning, is related to symptom relief but does not provide a direct measure of hydration. In an educational context, understanding the signs of dehydration and effective fluid resuscitation is crucial in managing patients with diarrhea. By recognizing the importance of skin turgor assessment, nurses can accurately gauge hydration status and tailor interventions accordingly to promote optimal patient outcomes.