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 ["A","B","D"]

Explanation

Choice A Reason: This is correct because melanoma is a type of skin cancer that arises from melanocytes, which are cells that produce pigment. Melanoma lesions are often irregular in shape and color, and may have different shades of brown or black.

Choice B Reason: This is correct because melanoma is a very aggressive and invasive type of skin cancer that can spread quickly to other parts of the body through the blood or lymphatic system. Melanoma has a high mortality rate if not detected and treated early.

Choice C Reason: This is incorrect because warm and red skin around a lesion may indicate inflammation or infection, but not necessarily melanoma. Melanoma lesions may have other signs, such as bleeding, itching, or ulceration.

Choice D Reason: This is correct because melanoma is associated with exposure to ultraviolet (UV) radiation from sunlight or artificial sources, such as tanning beds. UV radiation can damage the DNA of melanocytes and cause them to grow abnormally.

Choice E Reason: This is incorrect because melanoma lesions are usually not painful unless they are ulcerated or infected. Pain may be a sign of other types of skin conditions, such as burns, blisters, or cuts.

A. Measure the abdominal girth B. Have the client extend their arms C. Have the client flex and extend their foot D. Ask the client to walk heel to toe

Correct Answer is B

Explanation

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics?

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

Explanation

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Correct Answer is B

Explanation

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