A 72-year-old patient was admitted with epigastric pain caused by a peptic ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?
Chest pain relieved with eating or drinking water
Burning epigastric pain 90 minutes after breakfast
Back pain three or four hours after eating a meal
Rigid abdomen and vomiting following indigestion
The Correct Answer is D
Choice A rationale
Chest pain that is relieved with eating or drinking water is not typically indicative of a complication from a peptic ulcer. This symptom may be related to conditions like gastroesophageal reflux disease (GERD).
Choice B rationale
Burning epigastric pain after eating is a common symptom of a peptic ulcer and, while uncomfortable, does not usually require an urgent change in the plan of care unless it significantly worsens or is accompanied by other concerning symptoms.
Choice C rationale
Back pain after eating can be associated with a peptic ulcer if the ulcer is located at the back of the stomach or the pain radiates; however, it does not typically warrant an urgent change in care without other symptoms.
Choice D rationale
A rigid abdomen and vomiting following indigestion can indicate a perforated ulcer, which is a medical emergency. This requires immediate intervention and possibly surgical consultation, thus warranting an urgent change in the nursing plan of care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
Correct Answer is C
Explanation
Choice A rationale
Hemorrhage refers to bleeding, which can be a serious complication of peptic ulcer disease but does not lead to the spilling of gastric contents into the peritoneal cavity.
Choice B rationale
Dumping syndrome is a condition where food moves too quickly from the stomach to the small intestine, which can cause symptoms like nausea and abdominal pain, but it does not involve the leakage of gastric contents into the peritoneal cavity.
Choice C rationale
Perforation is the correct answer because it describes a hole forming in the wall of the stomach or duodenum, allowing gastric contents to spill into the peritoneal cavity, leading to peritonitis, which is a severe and life-threatening condition.
Choice D rationale
Gastric outlet obstruction is a blockage at the end of the stomach that prevents contents from entering the small intestine, which can cause vomiting and abdominal pain, but it does not result in the leakage of gastric contents into the peritoneal cavity.
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