A client arrives to the emergency department complaining of acute onset of nausea with projectile vomiting. The nurse's assessment findings include high-pitched sounds in the left upper quadrant. Which gastrointestinal disorder is consistent with these findings?

Colorectal cancer

Paralytic ileus

Large bowel obstruction

Small bowel obstruction

Answer and Explanation

The Correct Answer is D

Choice A Reason: Colorectal cancer is not likely to cause nausea with projectile vomiting or high-pitched sounds in the left upper quadrant. Colorectal cancer may cause symptoms such as rectal bleeding, change in bowel habits, abdominal pain, or weight loss.

Choice B Reason: Paralytic ileus is a condition where the bowel stops working and does not contract or move food along. Paralytic ileus may cause symptoms such as abdominal distension, absence of bowel sounds, constipation, or vomiting.

Choice C Reason: Large bowel obstruction is a blockage of the colon or rectum that prevents the passage of stool. Large bowel obstruction may cause symptoms such as abdominal distension, low-pitched sounds in the right lower quadrant, constipation, or ribbon-like stools.

Choice D Reason: Small bowel obstruction is a blockage of the small intestine that prevents the passage of food and fluids. Small bowel obstruction may cause symptoms such as nausea with projectile vomiting, high-pitched sounds in the left upper quadrant, abdominal cramps, or dehydration.

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Correct Answer is ["B","D","F"]

Explanation

Choice A Reason: Slow even breathing is not a sign of Cushing's Triad, which is a late indicator of increased intracranial pressure (ICP). The breathing pattern may be altered due to brainstem compression, but not necessarily slow or even.

Choice B Reason: This is a correct answer because bradycardia and bounding pulse are part of Cushing's Triad, which reflects an increased vagal tone and decreased cardiac output due to increased ICP.

Choice C Reason: Systolic hypotension with a narrowing pulse pressure is not a sign of Cushing's Triad, which involves an increased systolic blood pressure and a widened pulse pressure due to increased ICP. Hypotension may occur due to shock or hemorrhage, but not as a result of increased ICP.

Choice D Reason: This is a correct answer because irregular respirations are part of Cushing's Triad, which reflects impaired respiratory control due to brainstem compression from increased ICP. The respirations may be Cheyne-Stokes, central neurogenic hyperventilation, apneustic, or ataxic.

Choice E Reason: Tachycardia and bounding pulse are not signs of Cushing's Triad, which involves bradycardia and bounding pulse due to increased ICP. Tachycardia may occur due to pain, anxiety, fever, or hypoxia, but not as a result of increased ICP.

Choice F Reason: This is a correct answer because systolic hypertension with a widening pulse pressure are part of Cushing's Triad, which reflects an increased cerebral perfusion pressure due to increased ICP. The diastolic blood pressure remains stable or decreases, resulting in a widened pulse pressure.

A. Request the charge nurse put the client on the surgery schedule B. Document the WBC count from the morning labs C. Notify the healthcare provider D. Provide an antiemetic

Correct Answer is C

Explanation

Choice A Reason: Requesting the charge nurse put the client on the surgery schedule is not the best first action, as it does not address the urgency of the situation. The client may have a perforated appendix, which is a life-threatening complication that requires immediate intervention.

Choice B Reason: Documenting the WBC count from the morning labs is not the best first action, as it does not address the client's current condition. The WBC count may be elevated due to inflammation or infection, but it does not indicate the severity of the problem.

Choice C Reason: This is the correct choice. Notifying the healthcare provider is the best first action, as it alerts them to the possibility of a perforated appendix and allows them to order appropriate tests and treatments.

Choice D Reason: Providing an antiemetic is not the best first action, as it does not address the underlying cause of the vomiting. The client may have peritonitis, which is inflammation of the abdominal cavity due to leakage of intestinal contents. An antiemetic may mask this symptom and delay diagnosis and treatment.

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A client arrives to the emergency department complaining of acute onset of nausea with projectile vomiting. The nurse's assessment findings include high-pitched sounds in the left upper quadrant. Which gastrointestinal disorder is consistent with these findings?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following manifestations will the nurse expect to find? (Select all that apply.)

Correct Answer is ["B","D","F"]

Explanation

Correct Answer is C

Explanation

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