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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect. Inability to read is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a stroke or a brain tumor. Meningitis does not affect the language or cognitive functions, but rather the meninges or the membranes that cover the brain and spinal cord.
Choice B Reason: This choice is incorrect. Bruising around the eyes is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has a basilar skull fracture or a head trauma. Meningitis does not cause bleeding or bruising, but rather inflammation and infection of the meninges.
Choice C Reason: This is the correct choice. A throbbing headache is a finding that the nurse should expect in a client who has meningitis, as it is one of the most common and characteristic symptoms. A throbbing headache is caused by increased intracranial pressure and irritation of the meninges due to inflammation and infection.
Choice D Reason: This choice is incorrect. A heart rate of 50 is not a finding that the nurse should expect in a client who has meningitis, but rather a possible finding in a client who has bradycardia or a slow heart rate. Meningitis does not affect the heart rate, but rather the temperature and blood pressure. The nurse should expect to see fever and hypotension in a client who has meningitis.
Correct Answer is ["D","E"]
Explanation
Choice A Reason: This choice is incorrect. Placing the client into a supine position is not an action that the nurse should take, as it can compromise the airway and increase the risk of aspiration. The nurse should position the client on their side with their head tilted slightly forward to allow saliva and secretions to drain out of their mouth.
Choice B Reason: This choice is incorrect. Applying restraints is not an action that the nurse should take, as it can cause injury and increase agitation. The nurse should protect the client from harm by removing any objects or furniture that may cause harm and padding any hard surfaces with blankets or pillows.
Choice C Reason: This choice is incorrect. Inserting a bite stick into the client's mouth is not an action that the nurse should take, as it can cause injury and obstruction. The nurse should never force anything into the client's mouth during a seizure, as it can damage their teeth, gums, tongue, or jaw.
Choice D Reason: This is a correct choice. Loosening restrictive clothing is an action that the nurse should take, as it can improve breathing and circulation. The nurse should unbutton any tight collars, belts, or ties that may constrict the chest or neck.
Choice E Reason: This is a correct choice. Placing a pillow under the client's head is an action that the nurse should take, as it can prevent injury and provide comfort. The nurse should support the client's head with a soft pillow or cushion to prevent hitting it against any hard surfaces.
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